GIFT  OF    MRS.  DOROTHY  CHAPMAN    TO   THE    U.C.L.A.   LIBRARY 


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Surgical  Notes  from 
Four  Continents  and 
the  West  Indies  :  :  : 


BY 


NICHOLAS  ISENN,  M.D.,  Ph.D.,LL.D. 

Head  of  the  Department  of  Suri^ery^  Rush  Medical  Col- 
lege^ in  affiliation  with  the    University  of  Chicago ; 
Surg  con-in- Chief  St.  Joseph's  Hospital ;  Attend- 
ing Surgeofi  Presbyterian  Hospital;  Surgeon- 
General  of  Illinois;  Lieut.  -  Colonel  and 
Chief  of  Operating  Staff  with  the 
Anny  in  the  Field  during  the 
Spanish-American    War 


9 
1305 


PREFACE 


HIS  little  book  is  made  up  of  reprints  from 
American  Medicine  in  which  appeared  my 
communications  sent  from  many  different 
parts  of  the  world  during  my  travels  in  1902-1903.  The 
first  journey  was  made  on  the  occasion  of  the  Seventh 
Conference  of  the  International  Red  Cross,  which  con- 
vened in  St.  Petersburg,  Russia,  May,  1902,  which  I 
had  the  honor  to  attend  as  an  official  delegate  of  the 
United  States.  The  next  trip  was  made  during  my 
midwinter  vacation  in  .lanuary,  1903,  and  included  a 
visit  to  eight  islands  of  the  West  Indies.  The  last  two 
articles  relate  my  observations  made  in  Spain  as  an 
official  delegate  of  our  government  to  the  Madrid 
International  Medical  Congress.  On  all  of  these  travels 
I  spent  much  of  my  time  in  visiting  hospitals  and 
clinics  and  in  the  study  of  rare  tropical  diseases.  The 
'^  Surgical   Notes"    in  this   form   are  intended  for  my 


friends  at  home  and  abroad  to  whom  I  am  so  much 
indebted  for  the  material  and  information  they  contain. 
Owing  to  my  absence  from  home  at  the  time  most  of 
these  articles  appeared  I  had  no  opportunity  to  read 
the  proof  which  will  account  for  a  few  typographical 
errors  which  occur. 

X.   SEXX. 

Chicago,  September,  lOOa. 


TABLE    OF    CONTENTS 


1.  Medical  Paris. 

2.  Surgical  Observations  in  Berlin. 

3.  Renal  Surgery  as  Practised  by  Professor  James  Israel. 

4.  Professor  Hoffa's  Orthopedic  Work. 

5.  Professor  Sonneuburg  and  His  Appendicitis  Work  at   the 

Moabit  Hospital. 

6.  The  Seventh  Conference  of  the  International  Red  Cross. 

7.  The  Pirogoff  Museum,  St.  Petersburg. 

8.  Medical  Institutions  of  St.  Petersburg. 

9.  Constantinople  as  a  Medical  Center. 

10.  Medical  and  Surgical  Notes  from  Asia. 

11.  The  Hospitals  of  Jerusalem. 

12.  Medical  Practice  in  Cairo  and  Prevailing  Diseases  of  Egypt. 

13.  Professor  Nicoladoni's  Clinic,  Gratz. 

14.  The  Teaching  and  Practice  of  Surgery  in  the  Vienna  All- 

geraeine  Krankenhaus. 

15.  Surgical  Work  of  Professor  Von  Mosetig-Moorhof  in   the 

Vienna  Allgemeine  Krankenhaus. 

16.  Medical  London  in  Summer. 

17.  Professor  John  Berg's  Surgical  Clinic. 

5 


18.  Present  Surgical  Methods  in  the  General  Hospital,  Ham- 

bnrg-Eppendorf. 

19.  Hospital  Work  of  Dr.  Carl  Lauenstein. 

20.  Comparison  Between  Foreign  and  American  Surgery. 

21.  Glimpses  of  the  Practice  of  Medicine  and  Diseases  in  the 

West  Indies. 

22.  Echoes  from  the  Madrid  International  Medical  Congress. 

23.  The  Medical  Institutions  of  Madrid. 


[Reprinted  from  American  Medicine,  Vol.  Ill,    No.  23,  pages  965-966, 
June  4,  1902.1 


MEDICAL  PARIS. 

BY 

NICHOLAS  SENN,  M.D., 

of  Chicago,  111, 

During  the  period  of  the  greatest  prosperity  of  France, 
Paris  was  the  center  of  medical  science  of  the  world.  The  uni- 
versity and  great  hospitals  were  crowded  with  practitioners  and 
students  from  the  adjacent  and  most  remote  countries.  It  was 
generally  conceded  that  medical  education  could  not  be  finished 
without  a  more  or  less  prolonged  visit  to  the  great  medical 
institutions  of  Paris.  Nelaton,  Velpeau,  Malgaigne  and  Dupuy- 
tren  in  surgery ;  Louis,  Broussais,  Trousseau  and  Broca  in 
medicine,  were  some  of  the  strongest  attractions  whose  in- 
fluence molded  the  teaching  and  practice  of  the  art  and 
sciencpi  of  medicine  and  surgery  the  world  over.  Most  of 
the  books  written  by  these  distinguished  celebrities  were 
translated  into  English,  German  and  other  living  languages 
and  became  the  recognized  authorities  in  most  of  the  medical 
schools.  Medical  science  is  deeply  indebted  to  the  French 
investigators  who  have  done  so  much  in  eliminating  erroneous 
ideas  and  in  establishing  new  facts  by  original  research  and 
careful  clinical  observation.  Many  of  the  leading  medical 
men  of  Paris  of  recent  and  present  date  occupy  a  well-deserved 
prominent  and  influential  position  as  authors,  teachers,  scien- 
tists and  clinicians.  Without  a  Pasteur,  bacteriology  might 
have  remained  unborn  at  the  present  time.  Charcot  was  a 
profound  thinker  and  a  brilliant  clinical  teacher.  Peon  and 
Oilier  were  recognized  masters  in  laying  the  foundation  of 
modern  surgery.  Since  the  use  of  the  science  of  medicine 
in  France  it  has  at  no  time  gone  into  decline.  The  good  work  of 
progress  has  never  come  to  a  standstill,  but  the  influence  of  the 
French  school  has  no  longer  such  a  firm  hold  on  the  medical 
profession  outside  of  its  national  limits.  The  Vienna  school, 
under  the  leadership  of  Hyrtl,  Rokitansky,  Oppolzer,  Carl 
Braun  and  Billroth,  has  since  enjoyed  the  greatest  popularity 
and  wielded  the  strongest  influence  in  molding  the  medical 
ideas  during  the  middle  of  the  last  century.  Since  the  awaken- 
ing of  Germany  in  1871,  after  her  victorious  conquest  against 
France,  the  seed  of  science  has  flourished  upon  her  soil, 
and  has  yielded  fruit  which  in  quantity  and  quality  has  sur- 


passed  anything  heretofore  accomplished  in  the  same  space  <^f 
time.  With  the  political  victory  came  a  general  prosperity  which 
has  become  the  means  of  erecting  and  maintaining  scientific 
institutions  which  in  efficiency  surpass  those  of  any  other 
country.  The  universities  of  Germany,  with  their  model 
laboratories  and  hospitals,  have  become  the  acknowledged 
medical  centers  for  the  entire  world.  The  current  of  medical 
students  and  graduates  seeking  additional  advantages  has  l)een 
recently  turned  away  from  Vienna  in  the  direction  of  Germany. 
The  immense  clinical  material  offered  by  the  hospitals  of  Paris 
and  the  unexcelled  facilities  for  the  study  of  pathology  pre- 
sented by  the  Allgemeiues  Krankenhaus  and  other  large  hos- 
pitals of  Vienna  are  powerless  in  deviating  the  course  of  the 
present  current.  How  long  Germany  can  hold  this  supremacy 
is  impossible  to  predict.  It  is  not  so  difficult  to  predict  where 
the  next  temple  of  medicine  will  be  erected.  In  less  than  25 
years  the  United  States  will  be  the  Mecca  toward  which 
pilgrim  medical  students  from  all  climes  will  wend  their  way. 

Science  has  been  moving  westward  and  will  continue  to  do 
so  in  the  future.  The  United  States  is  in  its  direct  pathway  and 
will  be  reached  in  due  course  of  time.  There  can  be  but  very 
little  doubt  that  when  our  country  has  fulfilled  its  mission  the 
inheritance  will  next  be  appropriated  by  the  youngest  of  civil- 
ized nations— Japan.  The  young  vigorous  private  institutions 
so  richly  endowed  by  our  public-spirited  men  of  wealth  will 
become  the  great  centers  of  learning  and  will  meet  their  exalted 
future  requirements  in  a  way  that  will  astonish  the  outside 
world.  Paris  presents  today  clinical  advantages  of  far  reaching 
value  that  are  not  sufficiently  appreciated  by  those  who  feel  the 
needs  of  postgraduate  education.  Undoubtedly  one  of  the 
reasons  for  this  is  the  preference  given  by  our  students  to  the 
German  over  the  French  language  when  it  becomes  necessary 
to  acquire  another  language  for  the  purpose  of  completing  their 
medical  studies.  A  speaking  knowledge  of  French  is  prac- 
tically of  l)ut  little  use  to  our  practitioners,  while  the  large  per- 
centage of  German-speaking  patients  adds  much  to  the  desire  of 
mastering  this  language.  Another  inducement  for  obtaining  a 
practical  knowledge  of  the  German  language  is  the  richness  of 
the  German  medical  literature,  which  exceeds  by  far  that  of  any 
other  country.  Any  one  who  wants  to  keep  pace  with  rapid 
advances  of  medical  knowledge  must  be  familiar  with  the  deep 
researches  of  German  scientists  and  the  accurate  observations 
of  the  German  clinicians. 

A  Forenoon  at  the  ffopital  Teyion.  —  Duving  my  limited 
sojourn  in  Paris  I  spent  one  very  profitable  forenoon  at  the 
Hopital  Tenon.  This  is  one  of  the  older  hospitals  in  Paris.  It 
is  a  solid  stone  building  outside  of  the  great  business  center  of 


the  city  and  can  accommodate  1,000  patients.  On  that  particular 
day  I  had  the  pleasure  of  familiarizing  myself  somewhat  with 
the  surgical  technic  of  one  of  the  noted  surgeons  of  Paris— 
Dr.  Broca.  I  was  particularly  impressed  with  the  simplicity 
of  his  details  in  rendering  hands  and  field  of  operation  aseptic. 
Hand  disinfection  is  obtained  by  scrubbing  with  warm  water 
and  soap  and  by  immersion  for  a  short  time  in  a  1 :  2,000  bichlorid 
solution.  The  field  of  operation  is  disinfected  by  the  same 
means  after  the  patient  is  fully  under  the  influence  of  a  general 
anesthetic.  The  dressing  material  consists  of  plain  gauze  and 
absorbent  cotton  sterilized  by  dry  heat,  the  former  kept  ready 
for  use,  in  tin  boxes.  Chloroform  is  the  anesthetic  used,  dropped 
upon  a  thin  gauze  compress  held  in  contact  Math  the  face. 
Reverdin's  needle  is  used  in  suturing.  Inside  of  the  peritoneal 
cavity  silk  is  used,  outside  catgut.  The  harmonious  action 
between  operator  and  assistant  in  suturing  and  ligaturing  was 
a  pleasure  to  observe.  Dr.  Broca  is  a  very  expert  operator  and 
his  work  is  the  best  proof  of  his  familiarity  with  the  technic  of 
the  different  operations  and  his  vast  experience  in  the  operat- 
ing room.  He  uses  very  few  instruments  and  makes  free  use 
of  his  hands  in  separating  and  approximating  wound  surfaces. 
His  movements  are  quick  but  deliberate  and  certain.  During 
the  forenoon  he  performed  the  following  operations: 

Case  I. — Appendicitis  in  a  badly  nourished  boy  about  14 
years  of  age.  First  attack  ;  duration  nine  days.  Clinical  symp- 
toms were  mild.  There  was  no  swelling  in  the  ileocecal  region. 
Abdomen  was  flat.  An  incision  three  inches  in  length  over  the 
appendix  and  parallel  with  the  fibers  of  the  external  oblique 
muscle  was  made.  Internal  oblique  and  remaining  layers  were 
incised  to  the  same  extent.  There  were  adhesions.  Appendix 
was  not  enlarged,  but  very  vascular.  Subserous  amputation 
was  done.  Mucosa  of  stump  not  cauterized,  but  was  buried  by 
two  rows  of  Lembert  sutures  of  fine  silk.  Peritoneum,  internal 
oblique;  external  oblique  and  skin  were  united  separately  by 
continuous  catgut  suture. 

Case  II.— Boy,  aged  15.  Had  multiple  enchondroma  of 
metacarpal  bones  and  phalanges  of  left  hand.  The  tumors 
varied  in  size  from  a  hazelnut  to  a  pea.  Most  of  them  were 
central,  and  near  the  epiphyseal  lines.  Operation  without  elas- 
tic constriction.  Short  incision  over  center  of  tumor ;  removal 
of  tumor  by  excochleation.  Six  tumors  were  removed  in  this 
manner,  and  all  of  the  wounds  sutured  throughout. 

Case  III.— Patient  was  a  girl,  aged  12.  She  was  anemic,  and 
the  subject  of  tuberculosis  of  the  lymphatic  glands  in  the 
submental  and  left  parotid  region.  Glands  were  in  a  state  of 
far  advanced  caseation,  with  overlying  skin  discolored.  They 
were  removed  by  clean  excision.  In  the  parotid  region  a  thin 
mantle  of  parotid  tissue  was  removed  with  the  caseous 
glands  within  the  capsule  of  the  parotid.  Before  draining  and 
suturing,  the  wounds  were  touched  freely  with  a  10%  solution 
of  zinc  chlorid. 

Case  IA^. — Boy  10  years  of  age,  operated  upon  for  hypo- 
spadias.   Termination  of  urethra  half  way  between  glans  penis 


and  scrotum.  A  urethra  was  made  l3y  dissecting  upon  each 
side  a  narrow  quadrangular  flap,  Avhich  was  sutured  over  a 
catheter  inserted  into  the  bladder. 

The  operator  was  not  pleased  with  the  result  of  this  opera- 
tion, and  in  all  probability  next  time  will  make  use  of  the 
method  described  by  Dr.  Carl  Beck,  of  New  York,  which  has 
yielded  such  brilliant  results  in  such  cases  in  the  hands  of  this 
and  many  other  operators. 


[ReiDrinted  from  American   Medicine,  Vol.  IV,  No.  2,  pages  66-67, 
July  12,  1902.] 


SURGICAL  OBSERVATIONS  IN  BERLIN. 

BY 

NICHOLAS  SEXN,  M.D., 
of  Chicago,  111. 

Berlin  is  today  the  most  profitable  center  for  surgical  teach- 
ing in  the  world.  The  vast  clinical  material  is  in  the  hands  of 
men  who  know  how  to  utilize  it  in  teaching  not  only  the  art  but 
also  the  science  of  surgery.  The  German  surgeon  is  a  patholo- 
gist and  is  guided  in  his  diagnosis  and  work  by  his  knowledge 
of  the  etiology  and  pathologic  conditions  which  underlie  the 
morbid  conditions  he  is  called  upon  to  correct.  Berlin  is  the 
place  above  all  others  for  postgraduate  instruction.  Its  rich 
museums  and  well-equipped  laboratories,  the  numerous  clinics 
pertaining  to  all  branches  of  the  healing  art  offer  facilities  for 
practical  work  far  superior  to  those  of  any  other  medical  center. 
The  young  surgeon  can  prepare  himself  here  for  his  life  work 
by  visiting  the  clinics  of  von  Bergmann,  Konig,  Rose,  Sonnen- 
burg,  James,  Israel  and  Hahn,  men  whose  names  are  household 
words  wherever  modern  surgery  is  practised.  Nowhere  is  it 
more  apparent  than  in  Berlin  that  aseptic  precautions  have 
recently  become  very  mvich  simplified.  The  greatest  stress  is 
laid  on  the  mechanical  cleansing  of  hands  by  the  liberal  use  of 
warm  water  and  soap  followed  by  alcohol,  with  or  without  a 
previous  ablution  with  a  bichlorid  solution.  Rubber  gloves 
have  been  almost  entirely  discarded.  Ether  is  used  more  fre- 
quently than  heretofore.  Spinal  anesthesia  has  few  if  any 
advocates. 

Friedrichshain  HospitaL— This  is  one  of  the  great  hos- 
pitals for  the  deserving  sick  poor  of  Berlin.  It  is  built  on  the 
pavilion  plan  around  a  large  open  square.  The  main  entrance 
is  vis  a  vis  with  one  of  the  large  public  parks.  The  many  build- 
ings are  constructed  on  modern  plans,  and  harmonize  as  a 
whole.  The  operating  rooms  are  equipped  with  all  facilities 
for  aseptic  work,  and  are  well  supplied  with  all  necessary  sur- 
gical instruments.  The  institution  has  a  total  capacity  of  800 
beds,  of  which  number  250  are  set  aside  for  surgical  patients. 


rrofessor  Habn. 


Professor  Hahii's   ]^o?'^'.— Professor  Hahn  is  well  known  to 
the  surgical  world.    He  has  probaljlj'^  performed  more  opera- 

'ions  upon  the  stomach  than 
any  other  surgeon.  He  is  an 
indefatigable  worker,  and 
has  done  much  in  the  ad- 
vancement and  perfection  of 
surgical  techuic.  He  oper- 
ates every  morning  at  the 
Friedrichshain  at  10  o'clock. 
His  well-trained  nurses  and 
experienced  assistants  coji- 
tribute  much  to  facilitate  and 
lighten  his  arduous  daily 
routine  work.  The  asepsis 
in  his  operating  room  is  as 
nearly  perfect  as  it  can  be 
made  without  any  extra  dis- 
play of  precautionary  meas- 
ures. No  gauze  turbans  are 
seen  here  and  no  display 
of  white  trousers,  wooden  or  golf  shoes  or  rubber  boots. 
Hand  disinfection  is  made  by  thorough  scrubbing  with  hot 
water  and  potash  soap,  followed  by  sublimate  solution. 
Gloves  are  used  only  in  operations  for  septic  conditions, 
and  then  only  for  the  purpose  of  guarding  against  unnec- 
essary contamination  of  the  hands.  For  nine  years  he  has 
relied  on  silk  exclusively  as  a  suturing  and  ligature  mate- 
rial. In  operations  upon  the  gallbladder  he  occasionally  makes 
use  of  catgut.  In  his  practice  stitch  abscesses  very  rarely  occur. 
The  motto  in  his  operating  room  is  hoJi  tcmgere,  a  warning  to 
nurses  and  assistants  not  to  touch  anything  that  might  contami- 
nate the  hands  after  they  have  been  rendered  aseptic.  One  nurse 
threads  the  needles,  another  hands  the  instruments,  and  the 
third  handles  the  sponges.  One  assistant  administers  the  anes- 
thetic, the  second  assists  the  operator,  and  a  third  one  uses  the 
sponge.  Chloroform  vapor  from  the  Junker-Kappeler  appara- 
tus is  the  anesthetic  in  general  use.  The  visitors  permitted  to 
witness  his  operations  do  so  without  being  obliged  to  remove 
their  coats  or  wear  a  gown. 

During  the  most  difficult  operations  the  work  goes  on 
quietly  and  deliberately,  without  any  manifestations  of  impa- 
tience, showing  the  hand  of  a  master,  ample  and  careful  prepa- 
rations, and  the  value  of  skilled  assistants  and  well-trained, 
wideawake  nurses.  It  was  a  source  of  great  pleasure  and  profit 
to  me  to  witness  the  following  operations  : 


Case  I. — Gastrogastrostoiny  for  hour-glass  contraction  of 
the  stomach :  The  patient  was  a  woman  of  about  30  years  who 
had  been  suffering  for  several  years  from  indigestion  and  fre- 
quent and  sometimes  profuse  hemorrhages  from  the  stomach. 
The  patient  was  reduced  to  a  skeleton.  No  positive  diagnosis 
was  made  between  cancer  and  ulcer  of  the  stomach.  The 
incision  was  made  through  the  middle  of  the  umbilicus  with- 
out the  aid  of  grasping  forceps  by  lifting  up  the  abdominal  wall 
on  each  side,  incising  the  fold,  including  the  entire  thick- 
ness of  the  abdominal  wall,  when  the  incision  was  enlarged  up- 
ward by  cutting  with  scissors.  As  the  vertical  incision  did  not 
give  free  access  to  the  stomach  a  transverse  incision  including 
the  entire  rectus  muscle  was  made  on  the  left  side.  The  stom- 
ach was  found  divided  into  two  unequal  compartments,  the 
largest  one  on  the  cardiac  side,  by  a  cicatricial  band.  The  firm 
adhesions  about  the  smaller  curvature  made  it  impossible  to 
deal  directly  with  the  ulcer,  consequently  the  proper  course  to 
pursue  Avas  to  establish  a  new  and  free  communication  between 
the  pyloric  and  cardiac  compartments  of  the  stomach,  this 
was  done  by  makiog  a  gastrogastrostomy  by  suturing.  The 
techuic  of  this  part  of  the  operation  was  perfection  itself. 
After  uniting  the  serous  surfaces  with  a  row  of  interrupted 
Lembert  stitches  in  a  vertical  direction  to  the  extent  of  three 
inches  the  muscular  and  serous  coats  were  incised  on  both  sides 
about  two  lines  from  the  line  of  suturing  and  another  row  of 
sutures  united  the  serous  surfaces  accurately,  when  the  mucous 
membrane  on  each  side  was  incised  and  sutured  separately 
w^ith  a  continuous  lockstitch  suture.  The  anterior  wound  mar- 
gins were  united  in  the  usual  manner  by  Czerny-Lembert 
sutures.  Although  the  patient  was  very  feeble  and  the  opera- 
tion consumed  70  minutes  symptoms  of  shock  were  absent. 
The  abdominal  incision  was  closed  by  two  rows  of  sutttres,  the 
first  including  all  layers  except  the  skin.  Three  small  capillary 
drains  of  gauze  were  inserted  between  the  external  sutures.  In 
applying  the  external  dressing-  abdominal  compression  is 
guarded  against  by  holding  the  internal  part  in  place  with  a 
number  of  strips  of  adhesive  plaster  which  encircle  only  one- 
half  of  the  circumference  of  the  body,  over  whicli  a  very  thick 
compress  of  absorbent  cotton  is  applied  and  held  in  place  by  a 
loose  gauze  roller.  Professor  Hahn  is  of  the  opinion  that  firm 
compression  favors  the  development  of  bronchial  and  pulmon- 
ary complications  after  abdominal  operations. 

Case  II.— Perforative  appendicitis:  Patient  a  woman  of 
66  years.  This  was  her  first  attack.  The  initial  symptoms  pre- 
sented nine  days  ago  were  comparatively  mild.  There  was  no 
rise  in  temperature,  but  there  was  some  vomiting  and  frequent 
eructations.  Rapidity  of  pulse  was  the  only  grave  prognostic 
symptom.  The  abdomen  was  tympanitic,  with  pain  and  tender- 
ness in  the  right  iliac  fossa.  A  muscle  splitting  incision  was 
made,  and  as  soon  as  the  peritoneal  cavity  was  opened  a  large 
quantity  of  thin  fetid  pus  escaped.  The  cavity  on  the  side  of  the 
small  intestines  was  tamponed  at  once  and  the  perforated 
appendix  was  brought  into  the  incision  without  any  difficulty. 
A  fecal  stone  escaped  Avith  the  pus  and  a  second  one  was  found 
in  the  blind  end  of  the  appendix.  The  perforation  through 
which  the  liberated  stone  had  escaped  was  found  near  the 
cecum.  The  first  ligature  cut  its  Avay  through  the  softened  tis- 
sues and  a  second  one  was  applied  with  less  firmness  to  the 
stump.  No  attempt  was  made  to  flush  the  cavity,  which  was 
then  loosely  packed  with  plain  sterile  gauze.    The  operator. 


from  a  very  large  expfrience,  has  fonudthat  the  tampon  should 
remain  in  place  from  five  to  ten  days  and  then  be  reduced  in 
size  gradually,  as  complete  removal  at  one  time,  according  to 
his  observations,  has  not  infrequently  proved  harmful.  By 
the  gradual  removal  of  the  tampon  the  suppurating  cavity  is 
reduced  in  size  as  the  foreign  material  is  extracted  and  the 
danger  of  damage  to  the  granulating  intestinal  loops  is  mini- 
mized. The  copious  external  dressing  is  changed  as  often  as 
indications  arise. 

Professor  Konig's  C/?/?/c.— Professor  Konig,  the  eminent 
author  and  present  authority  on  diseases  of  joints,  conducts  his 
clinic  at  the  Charite  Hospital  every  day  except  Sunday  at  half- 
past  nine  in  the  forenoon.  He  is  looking  forward  with  well- 
founded  impatience  to  the  completion  of  the  new  clinical  build- 
ing, as  the  present  quarters  are  entirely  inadequate  for  the 
existing  demands.  The  amphitheater  has  only  136  seats  alto- 
gether, insulficient  for  the  many  students  who  seek  instruction 
in  this  clinic.  The  seats  are  numbered  and  assigned  to  the 
students  who  are  fortunate  enough  to  receive  them  by  early 
application.  Professor  Konig  has  just  celebrated  his  seventieth 
birthday.  He  enjoys  robust  health  and  retains  the  enthusiasm 
of  youth.  It  does  appear  sometimes  sad  to  contemplate  that  great 
men  who  have  been  of  such  incalculable  assistance  to  science 
and  humanity  must  eventually  succumb  to  the  inevitable  senile 
decrepitude  which  at  last  conquers  their  physical  strength 
and  mental  activity.  Konig  has  always  been  an  impressive 
and  popular  teacher,  a  reputation  he  has  maintained  to  the 
highest  degree  since  he  came  from  Gottingen  to  Berlin.  His 
language  is  concise  and  precise.  Like  all  German  teachers  he 
makes  pathology  the  ground  floor  for  his  clinical  teachings. 
The  details  of  his  aseptic  technic  are  remarkable  for  their  sim- 
plicity. Hand  disinfection  consists  largely  of  thorough  scrub- 
bing with  hot  water  and  soap  supplemented  by  an  ablution 
with  a  1 1000  solution  of  mercury  bichlorid.  The  field  of  opera- 
tion is  disinfected  in  the  same  manner  after  the  patient  is  under 
the  influence  of  the  anesthetic.  If  rubber  gloves  were  ever  used 
they  have  been  discarded.  As  anesthetics,  chloroform  and  ether 
are  used.  I  will  give  a  brief  description  of  the  material  pre- 
sented and  the  operations  performed  during  one  of  his  clinics: 

Case  I. — Resection  of  the  head  of  the  radius  for  ankylosis 
of  the  eibowjoint  following  gonorrheal  arthritis. 

The  patient  was  a  female  of  25  years.  The  forearm  was 
fixed  in  flexion  at  an  angle  of  45°  with  complete  suspension  of 
all  rotary  movements.  The  acute  symptoms  had  subsided  and 
as  the  joint  resisted  all  attempts  at  immobilization  an  incom- 
plete resection  was  performed  a  few  days  ago.  On  opening  the 
joint  on  the  radial  side  a  bony  ankylosis  was  found  between 
the  articular  surfaces  of  the  radioulnar  joint.  The  excision  of 
the  head  of  the  radius  removed  the  mechanical  difficulty  and 
the  joiat  can  now  l^e  flexed  quite  freely  and  pronation  and 
supination  of  the  forearm  have  been  restored.     A  small  iodo- 


form  gauze  drain  was  removed  and  the  dressing  and  fixation 
splint  reapplied.  It  was  remarked  that  in  many  cases  of  anky- 
losis of  the  elbowjoint  arising  in  the  coarse  of  a  gonorrheal 
arthritis  the  mechanical  difficnity  is  often  to  befonnd  in  a  bony 
ankylosis  of  the  radioulnar  joint  and  that  a  resection  of  the 
head  of  the  radius  offers  the  only  chance  for  restoration  of 
motion. 

Case  II. — Fracture  of  the  humerus  at  the  junction  of  the 
middle  with  the  lower  third,  complicated  by  paralysis  of  the 
musculospiral  or  radial  nerve  and  delayed  union. 

In  this  patient,  a  robust  man  of  middle  age,  it  was  difficult 
to  decide  between  trauma  and  callus  compression  as  cause  of 
the  paralysis,  as  the  patient's  statements  in  reference  to  the 
time  when  the  paralysis  appeared  were  indefinite.  Four 
days  before  an  incision  was  made  over  the  course  of  the  nerve 
exposing  the  seat  of  the  fracture  freely.  The  fragments  were 
found  imbedded  in  a  mass  of  immature  callus,  and  the  nerve 
over  it  completely  severed.  The  proximal  end,  as  is  usually 
the  case,  was  bulbous.  The  finding  of  the  distal  end  was 
attended  by  considerable  difficulty.  Secondary  nerve  suturing 
was  performed  after  freely  vivifying  the  nerve  ends.  Accord- 
ing to  the  operator's  large  experience,  restoration  of  nerve 
function  is  often  delayed  for  months  after  the  operation  if 
the  operation  is  performed  a  long  time  after  the  injury.  The 
hope  was  expressed  that  the  nerve-suturing  would  hasten  the 
process  of  bone  repair. 

Case  III. — Large  abscess  in  left  iliac  fossa  of  somewhat 
doubtful  origin  ;  operation  four  weeks  ago. 

Patient  a  young  man  who  was  attacked  suddenly  with 
symptoms  of  peritonitis.  The  disease  pursued  a  very  rapid 
course  and,  in  view  of  the  clinical  symptoms,  appendicitis  was 
suspected  as  its  cause,  although  the  physical  signs  indicated 
an  accumulation  of  pus  in  the  left  iliac  region,  extending  over 
the  bladder  toward  the  right  side.  At  the  time  the  operation 
was  performed,  over  four  weeks  ago,  the  abdomen  was  very 
tympanitic.  Almost  the  entire  linea  alba  was  incised  but  noth- 
ing abnormal  could  be  found  in  the  peritoneal  cavity  except 
distention  of  the  small  intestines.  The  abdominal  incision 
was  then  closed  and  a  transverse  incision  made  over  the  pubes 
and  left  Poupart's  ligament  and  a  large  quantity  of  extremely 
offensive  pus  evacuated.  The  most  careful  exploration  did  not 
reveal  a  palpable  cause  for  the  suppurative  inflammation,  but 
it  is  suspected  that  an  abnormally  situated  appendix  was  the 
starting  point  of  the  infection.  The  large  cavity  becomes  oblit- 
erated in  a  remarkably  short  time  by  granulations,  and  the 
grave  symptoms  subsided  promptly  after  the  operation.  The 
abdominal  incision  is  healed  and  only  a  limited  granulating 
field  indicates  the  location  of  the  transverse  incision.  Gauze 
was  made  use  of  as  a  drainage  material.  Attention  was  called 
to  the  comparative  harmlessness  of  fetid  pus  in  dealing  with 
the  suppurative  inflammation  giving  rise  to  this  variety  of  pus. 

Case  IV.— Fetid  empyema  following  rupture  of  an  appen- 
diceal abscess  into  the  left  pleural  cavity. 

This  case  was  an  extremely  obscure  one.  The  patient,  a 
young  man  of  16,  when  admitted  into  the  hospital  presented  all 
the  indications  of  empyema.  The  early  history  of  the  case  was 
obscure.  A  segment  of  the  seventh  rib  was  excised  in  the  axil- 
lary line  and  a  large  quantity  of  very  fetid  pus  was  liberated.  The 
patient  not  improving  as  was  expected,  the  opening  in  the  chest 
wall  was  enlarged  by  resection  of  the  adjacent  lower  rib.    As 


6 

the  suppuration  and  septic  condition  persisted,  it  Avas  finally 
decided  to  follow  the  abscess  cavity  its  entire  length  in  a  down- 
ward direction.  The  remaining  lower  ribs  were  excised  and 
a  perforation  was  found  in  the  diaphragm.  The  aljscess  cavity 
was  followed  by  extending  the  incision  downward  as  far  as  the 
crest  of  the  ilium.  From  this  time  the  patient  improved 
rapidly  and  at  the  present  time  the  enormous  wound  is  granu- 
lating satisfactorily  and  promises  to  heal  in  a  short  time.  It  is 
believed  that  an  appendicitis  was  the  cause  of  abscess  forma- 
tion and  that  the  secondary  suppurative  pleuritis  resulted  from 
the  entrance  of  pus  into  the  pleural  cavity  through  a  perfora- 
tion in  the  diaphragm. 

Case  V.— Diffuse  peritonitis  following  appendicitis  ;  opera- 
tion. 

Patient  a  delicate  girl  of  10  years.  This  was  her  first  attack, 
the  duration  of  the  disease  being  less  than  two  weeks.  The 
symptoms  were  strong  from  the  beginning,  vomiting  was  a 
prominent  symptom.  The  abdomen  was  distended,  and  the 
presence  of  pus  in  the  right  iliac  fossa  was  suspected.  The  per- 
sistent vomiting,  feeble  circulation  and  marked  tympanites 
were  regarded  as  grave  symptoms.  A  long  incision  was  made, 
and  as  soon  as  the  peritoneal  cavity  was  opened  a  large  quan- 
tity of  fetid  pus  escaped.  Intraperitoneal  palpation  proved 
that  the  peritonitis  was  diffuse,  with  no  tendencv  to  limitation. 
The  incision  was  then  enlarged  upward  along  the  crest  of  the 
ilium.  There  was  free  prolapse  of  small  intestines  and  cecum. 
The  inflamed  appendix  came  readily  into  the  wound,  was 
ligated  and  removed.  There  was  no  gangrene  and  no  perfora- 
tion. The  stump  was  buried  with  a  few  Lembert  stitches. 
The  pus  was  pushed  out  by  placing  the  patient  on  the  right  side 
and  the  wound  packed  with  iodoform  and  sterile  plain  gauze. 
The  extent  of  the  disease  was  mentioned  as  a  contra-indicatiou 
to  irrigation. 

Case  VI.— Carcinoma  of  the  posterior  wall  of  the  rectum  : 
extirpation. 

This  patient  was  a  woman  of  66.  For  twenty  years  she  suf- 
fered from  a  rectal  difficulty  which  was  regarded  to  be  of  a 
hemorrhoidal  nature.  The  prominent  tumor  excavated  in  the 
center  projected  from  the  posterior  rectal  wall  one  and  one-half 
inches  above  the  anus.  The  patient  was  placed  in  the  lith- 
otomy position  and  the  anterior  rectal  wall  removed  farljeyond 
the  limits  of  the  tumor  by  the  perineal  route.  The  importance 
of  making  a  careful  examination  in  all  cases  of  rectal  disease 
was  emphasized.  Like  most  surgeons.  Professor  Konig,  as 
the  result  of  experience,  has  been  led  to  limit  more  and  more 
the  indications  for  Kraske's  sacral  resections  as  a  preliminary 
step  to  operations  for  malignant  disease  of  the  rectum. 
Berlin,  May  15. 


LHeprinted  from  American  Medicine,  Vol.  IV,  No.  3,  pages  103-104, 
July  19,  1902.1 


SURGICAL  OBSERVATIONS  IN  BERLIN. 

Professor  Olshausen's  Gynecologic  Clinic. — The  Augusta 
Hospital. 


NICHOLAS  SENN,  M.D., 
of  Chicago. 

Professor  Olshausen  occupies  today  the  highest  position 
as  a  teacher  of  gynecology.  As  an  operator  he  is  one  of  the  prin- 
cipal attractions  of  the  medical  faculty  of  the  University.  He 
left  Halle  in  1887,  w^hen  50  years  of  age.  His  success  in  Berlin 
has  been  phenomenal.  The  clinical  material  over  which  he  has 
complete  control  is  immense.  Four  laparotomies  a  day  is  a 
small  estimate  of  his  daily  major  operations.  Every  one  of  his 
operations  shows  the  hand  of  a  master.  He  is  never  in  haste, 
and  yet  the  operations  are  performed  quickly.  The  most 
difficult  operations  are  performed  with  few  instruments.  He 
handles  the  instruments  with  an  accuracy  and  dexterity  that 
astonish  and  charm  his  audiences.  His  earnestness  and  enthu- 
siasm in  the  lecture  and  operating  room  are  impressive. 
Among  his  private  patients  are  to  be  found  the  names  of  many 
of  the  most  prominent  families  from  every  country  on  the  con- 
tinent. His  speech  and  actions  are  well  calculated  to  inspire 
patients  and  pupils  with  confidence.  He  begins  his  operations 
at  7  o'clock  in  the  morning  and  seldom  finishes  his  onerous 

task  before  midday.  No  time 
is  wasted.  He  is  punctual  to 
the  minute.  His  splendid 
staff  of  assistants  and  well- 
trained  nurses  anticipate  all  of 
his  wants,  and  the  most  com- 
plicated operations  are  fin- 
ished without  a  hitch  or  a 
harsh  word. 

Chloroform  by  the  drop 
method  is  the  anesthetic  used. 
Sublimate  alcohol  catgut  is  the 
exclusive  suture  and  ligature 
material  used  with  one  excep- 
tion, intestinal  operations, 
when  silk  takes  its  place. 
Cathartics  are  given  before 
Professor  Olshausen.  abdominal  section  and  three 

days  after  operation.    The  day 
before  operation  the  patient  is  given  a  bath,  but  the  disinfection 


of  the  field  of  operation  does  not  take  place  until  the  patient  is 
on  the  operating  table  and  fully  under  ihe  influence  of  the  gen- 
eral anesthetic. 

This  disinfection,  as  well  as  hand  disinfection,  consists 
largely  in  prolonged  scrubbing  with  hot  water  and  soap,  fol- 
lowed by  sublimate  solution  and  alcohol.  The  last  antiseptic 
is  now  considered  the  most  important  in  guarding  against 
stitch  abscesses. 

The  instruments,  on  a  tray,  are  placed  on  a  stand  within  easy 
reach  of  the  operator.  One  nursie  threads  and  hands  the  needles. 
A  second  nurse  hands  the  sponges  and  the  dressing  material  in 
a  receptacle,  without  touching  them.  The  two  great  rules  that 
should  govern  the  work  in  every  operating  room  are  displayed 
conspicuously.  These  rules  are :  ""Noli  tangere''''  and^'Favete 
Unguis."  One  assistant  assists  the  operator,  a  second  admin- 
isters the  anesthetic  and  a  third  holds  the  pulse.  The  leading 
points  in  his  operative  technic  will  be  given  in  a  few  of  the 
operations  I  had  an  opportunity  to  witness. 

Case  I. — Enucleation  of  a  Myofibroma  of  the  Uterus.  The 
patient  was  31  years  old;  Trendelenburg  position.  Disinfection 
of  the  abdomen  was  obtained  by  shaving,  scrubbing  with 
warm  water  and  soap,  followed  by  sublimate  solution  and 
alcohol.  Incision  was  made  through  the  linea  alba.  Peri- 
toneum was  opened  in  the  upper  angle  of  the  wound  so  as  to 
avoid  injury  to  the  bladder.  Incision  was  enlarged  to  the 
extent  of  five  inches  with  blunt-pointed  scissors.  Uterus  was 
lifted  forward  into  the  wound  and  a  large  compress  of  gauze 
placed  between  it  and  the  small  intestines.  To  this  large  gauze 
compress  a  tape  was  fastened,  and  to  the  end  of  the  tape  a  large 
hemostatic  forceps  was  applied.  These  precautions  cannot  fail 
to  prevent  the  loss  of  gauze  in  the  abdominal  cavity.  The 
tumor,  the  size  of  an  orange,  involved  the  summit  of  the  uterus 
and  was  interstitial.  The  mantel  of  uterine  tissue  was  incised 
half  way  between  the  cornua  in  an  anteroposterior  direction, 
when  the  tumor  was  grasped  with  vulsella  forceps  and  easily 
removed  by  enucleation.  This  part  of  the  operation  was  done 
largely  by  stripping  the  uterine  tissue  back  with  a  gauze  sponge. 
The  bleeding,  which  was  very  slight,  was  carefully  arrested  by 
ligating  with  catgut.  The  visceral  wound  was  closed  by  two 
rows  of  continued  catgut  sutures,  the  first  row  including  the 
muscle  tissue  and  the  second  one  approximately  the  serous  sur- 
faces. The  bleeding  from  the  needle  punctures  was  arrested  by 
additional  sutures  often  placed  parallel  with  the  line  of  incision. 
The  peritoneum  was  sutured  separately  with  a  continued  catgut 
suture,  the  second  tier  included  the  fascia,  and  the  third  approx- 
imated the  skin.  A  drying  powder  was  rubbed  into  the  punc- 
tures of  the  skin,  and  the  dressing,  consisting  of  a  few  layers 
of  gauze  and  a  compress  of  aseptic  absorbent  cotton,  fastened  in 
place  by  three  broad  strips  of  adhesive  plaster.  Professor 
Olshausen  is  of  the  opinion  that  ventral  hernia  after  laparotomy 
only  occurs  when  the  fascia,  from  faulty  suturing  or  suppura- 
tion, fails  to  unite.  He  has  no  confidence  in  abdominal  sup- 
porters as  preventives  of  this  post-operation  complication. 

Case  11.— Multiple  Myofibroma  of  the  Uterus:  Supra- 
vaginal Amputation.    The  patient  is  a  multipara,  47  years  old. 


The  uterus  and  tumors  form  a  nodular,  irregular  mass  the  size 
of  an  infant's  head.  The  right  ovary  is  healthy,  and  the  left  one 
cystic.  The  latter  was  removed  with  the  uterus.  Division  of 
tubes  and  broad  ligaments  was  made  between  double  catgut 
ligature.  The  ovarian  arteries  were  ligated  en  masse.  The 
uterus  was  now  drawn  well  forward  and  upward  with  traction 
forceps,  the  peritoneum  incised  and  reflected  largely  by  pres- 
sure with  gauze  sponge.  All  bleeding  points  were  tied  with 
catgut,  after  which  the  uterus  was  amputated  with  one 
sweep  of  the  knife.  Projecting  bloodless  stumps  of  ovarian 
arteries  were  tied  sepai-ately.  The  cut  surface  of  uterine  tissue 
was  approximated  by  continued  catgut  sutures  when  the  serous 
surfaces  were  carefully  united  by  the  same  kind  of  suture. 
Abdominal  incision  was  closed  and  dressed  in  the  same  manner 
as  in  the  first  case. 

Case  111.— Retroversion  of  Uterus:  Alexander's  Operation. 
Professor  Olshauseu  commenced  to  perform  this  operation  only 
three  years  ago,  and  is  very  careful  in  the  selection  of  cases.  He 
limits  the  operation  to  cases  of  retroversion  of  a  movable 
uterus  which  produces  symptoms  of  suflQcient  severity  to  war- 
rant operative  interference.  In  this  case  the  uterus  could  be 
brought  into  normal  position  without  any  difficulty.  An 
incision  three  inches  in  length  was  made  from  the  pubic  spine 
and  parallel  with  Poupart's  ligament.  After  incising  the  skin 
and  superficial  fascia,  the  lower  angle  of  the  inguinal  canal 
where  the  round  ligament  expands  and  is  attached  was  sought 
for  by  rubbing  with  a  gauze  sponge.  The  ligament  was  iso- 
lated at  this  point,  grasped  with  hemostatic  forceps,  divided 
below  the  forceps,  and  then  taking  the  ligament  as  a  guide  the 
inguinal  canal  was  slit  open  with  probe-pointed  scissors,  the 
ligament  detached  and  by  traction  and  backward  rubbing  with 
a  sponge  liberated  to  the  extent  of  about  four  inches.  The 
ligament  was  fastened  in  the  canal  by  four  transfixion  catgut 
sutures,  the  free  end  excised  and  the  little  wound  closed  by  two 
rows  of  catgut  sutures.  Dusting  powder  and  a  small  aseptic 
absorbent  dressing  held  in  place  with  roller  bandage  finished 
the  operation.  The  operation  on  the  opposite  side  w^as  per- 
formed in  thp  same  manner.  The  experience  of  the  operator 
concerning  the  remote  results  of  this  operation  has  been  very 
satisfactory. 

The  wealth  of  material  of  this  clinic  is  shown  by  the  fact 
that  about  700  patients  suffering  from  retroversion  of  the  uterus 
apply  annually  for  relief.  Out  of  this  number  only  from  35  to 
40  cases  are  selected  for  an  Alexander's  operation. 

Augusta  Hospital.— This  institution  for  the  relief  of  the 
sick  of  Berlin  has  an  interesting  history.  It  was  founded  by  the 
late  Empress  Augusta  and  has  been  a  favorite  resort  for  the  sick 
for  more  than  a  quarter  of  a  century.  It  is  managed  by  the 
Women's  Hospital  Association,  of  which  the  Empress  is  honor- 
ary president.  It  is  probably  the  naost  homelike  hospital  in  the 
world.  Its  officers  and  Sisters  are  selected  exclusively  from  the 
titled  nobility.  In  a  large  and  beautifully  furnished  room  the 
Board  of  Managers  holds  its  meetings,  the  Empress  or  her  sub- 
stitute presiding.  Here  are  found  portraits  of  the  royal  family 
and  a  register  for  distinguished  visitors  contains  the  names  of 


most  of  the  distinguished  men  and  women  of  the  German  Em- 
pire. The  hospital,  which  has  a  capacity  of  190  beds,  presents  a 
homelike  appearance  and  is  surrounded  by  ample  grounds,  made 
attractive  by  expert  gardeners.  The  furniture  throughout  the 
entire  house  reminds  one  of  the  comforts  of  a  private  home. 
Two  of  the  most  distinguished  medical  men  in  Berlin  are  at  the 
head  of  the  medical  service.  Professor  Ewald  has  charge  of  the 
medical  and  Professor  Fedor  Krause  of  the  surgical  depart- 
ment. These  appointments  are  made  by  the  Empress  and  are 
for  life.  Professor  Krause  imbibed  his  unbounded  enthusiasm 
from  his  distinguished  teacher,  the  late  Professor  von  Volk- 
mann.  He  has  written  a  valuable  monograph  on  tuberculosis 
of  joints,  and  for  a  number  of  years  had  charge  of  the  surgical 
work  of  the  Altona  Hospital.  Recently  he  has  distinguished 
himself  in  brain  and  nerve  surgery.     He  received  the  present 


Augusta  Hospital. 


appointment  a  year  and  a  half  ago,  and  is  now  in  direct  line  for 
early  promotion.  The  care  of  the  sick  is  in  charge  of  Sisters 
and  nurses  who  receive  their  theoretic  instructi  )n  and  practical 
training  in  the  hospital.  The  Sister  Superior  receives  her 
appointment  from  the  Empress.  Sister  von  Arnim  has  served 
in  this  capacity  since  the  hospital  was  opened.  All  of  the 
Sisters,  20  in  number,  are  of  noble  birth.  The  initia- 
tion of  a  Sister  is  an  important  event,  at  which  the 
Empress  is  always  present,  and  presents  the  Golden 
Roman  Cross  she  is  expected  to  wear  during  her  service  of 
the  balance  of  her  lifetime.  The  selection  of  nurses  receives 
the  same  care.  They  are  young  ladies,  from  20  to  25  years  of 
age,  usually  the  daughters  of  clergymen  or  professors.  These 
nurses  very  rarely  abandon  their  profession.  The  nurses  must 
remain  m  training  for  two  or  three  years,  and  during  this  time 


they  are  instructed  in  the  theoretic  part  of  their  profession  for 
three  months  by  tlie  senior  home  physician,  who  gives  two 
lectures  a  week. 

The  lectures  are  of  the  most  practical  kind.  At  the  expira- 
tion of  the  specified  time  they  receive  a  certificate  of  proficiency 
from  the  Si.ster  Superior  and  are  permitted  to  enter  private 
practice  or  hospital  work  in  some  other  institution.  The  earn- 
ings of  these  nurses  flow  into  the  treasury  of  the  institution 
from  which  they  graduated.  On  the  other  hand,  their  alma 
mater  provides  at  all  times  for  their  subsistence  and  clothing. 

In  Germany  the  loss  of  a  nurse  by  marriage  does  not  occur 
as  frequeritly  as  in  our  own  country,  where  the  attractive  and 
most  efficient  nurses  only  too  often  leave  their  chosen  profes- 


5r 


Augusta  Hospital  and  Garden, 

sion  by  entering  married  life,  an  occurrence  which  cannot  fail 
in  weakening  the  nursing  prof'-ssion.  In  time  of  war  or 
other  great  national  calamities,  Sisters  and  nurses  are 
subject  to  call  from  the  Red  Cross  Society  of  Germany, 
with  which  this  institution  is  identified.  There  is  perhaps  no 
other  hospital  in  which  the  sick  recei\e  better  atten- 
tion. A  patient  who  pays  §1.25  a  day  is  entitled  to  a  pri- 
vate room  with  two  beds,  and  §2.50  a  day  a  single  room 
including  the  very  best  nursing  and  medical  or  surgical 
attendance.  The  salary  of  the  attending  surgeon  is  less  than 
§400  a  year.  The  income  of  the  mediral  profession  of  Germany 
is  greatly  reduced  by  the  questionable  custom  which  prevails 
in  all  hospitals  throughout  the  em|»i]-e  of  rendering  fiee  medi- 


6 


cal  service  to  private  patients  occupying  the  most  luxurious 
rooms  and  by  the  only  too  prevalent  contract  practice  among 
the  laboring  classes. 

Professor  Krause's  Work. — Professor  Krause  belongs  to  the 
younger  class  of  progressive  surgeons  of  this  city.  His  present 
field  offers  him  abundant  and  very  interesting  clinical  material. 
In  the  laboratory  connected  with  the  hospital  excellent  patho- 
logic work  is  done.  I  examined  here  a  large  collection  of 
specimens  of  carcinoma  of  the  pylorus  removed  by  operation. 
Gastrectomy  and  gastroenterostomy  are  frequently  performed 
in  this  hospital,  as  Professor  Ewald,  who  has  charge  of  the 
medical  service,  refers  his  cases  which  require  operative  inter- 
ference to  the  surgical  department.  Two  tumors  of  the  spinal 
cord  were  also  shown.  One  of  the  tumors  was  a  psammoma 
the  size  of  a  hazelnut  removed  successfully  from  the  dorsal  sec- 
tion of  the  spinal  cord.  The  symptoms  before  the  oper- 
ation were  so  characteristic  that  the  surgeon  was  able 
to  make  an  absolute  anatomic  and  pathologic  diag- 
nosis. Paralysis  of  motion  on  one  side  and  loss  of  sensa- 
tion on  the  opposite  were  the  most  conspicuous  clinical 
features.  The  cord  was  freely  exposed  by  resection  of  three 
vertebral  arches.  The  dura  was  incised  and  the  encapsulated 
tumor  removed  by  enucleation.  Nerve  function  has  been 
restored  sufficiently  so  the  patient  walks  readily  with  the  use  of 
a  cane.  The  other  specimen  illustrated  the  diffuse  nature  of 
sarcoma  of  the  spinal  cord.  The  tumor  had  its  origin  in  the 
Cauda  equina  and  was  exposed  by  an  extensive  laminectomy 
and  was  followed  upward  sufficiently  far  to  satisfy  the  operator 
that  the  case  was  hopeless.  The  patient  died.  Krause  has  had 
a  very  extensive  experience  in  nerve  and  brain  surgery.  In 
neuralgia  of  the  trifacial  nerve  he  always  resorts  to  peripheral 
operation  first.  A  beautiful  collection  of  excised  nerves  was 
demonstrated.  From  the  point  where  tbe  nerve  is  attached  the 
main  trunk  and  branches  are  followed  as  far  as  possible 
so  as  to  make  the  extracranial  excision  thorough.  If  the 
operation  does  not  prove  successful  he  resorts  to  his  intra- 
cranial operation  for  the  removal  of  the  Gasserian  ganglions. 
He  has  performed  this  operation,  up  to  the  present  time,  on  36 
patients.  Only  three  of  these  patients  died  from  the  effects  of 
the  operation;  in  those  that  survived  the  relief  was  prompt 
and  permanent  except  in  one,  in  whom  it  failed  to  mitigate  the 
pain.  This  patient  wa,s  a  physician,  who  threatened  to  commit 
suicide  if  the  operation  were  refused.  The  cause  of  the  pain  in 
this  patient  had  a  deeper  and  inaccessible  origin. 


[Reprinted  from  American  Medicine.  Vol.  IV,  No.  4  page  148, 
July  26,  1902.] 


RENAL    SURGERY  AS  PRACTISED   BY  PROFESSOR 
JAMES  ISRAEL. 


NICHOLAS  SENN,  M.D., 
of  Chicago. 

The  world  admires  the  work  of  a  master.  This  applies  not 
only  to  art,  music,  science,  literature,  war  and  oratory,  but  also 
to  surgery.  The  fame  of  the  artist,  musician,  scientist,  littera- 
teur, warrior  and  orator  spreads  worldwide  and  is  immor- 
talized in  prose  and  song;  that  of  the  master  surgeon  is  limited 
to  within  the  narrow  bounds  of  the  profession  he  represents. 
To  my  mind  there  can  be  no  greater  source  of  satisfaction  than 
to  excel  in  Avork  calculated  to  advance  science  and  bene- 
fit suffering  humanity.  The  master  surgeon  occupies  such 
a  position.  He  belongs  to  the  most  charitable  of  all  profes- 
sions. His  genius  adds  to  the  advancement  of  science,  his 
art  benefits  the  poor  as  well  as  the  rich.  The  surgeon  who 
makes  a  careful  and  exhaustive  study  of  the  diseases  of  an  im- 
portant organ  and  devises  new  measures  of  relief  merits  the 
admiration  and  gratitude  not  only  of  the  members  of  the  pro- 

^ fession  to  which  he  belongs 

but  of  the  entire  world. 
Such  a  man  is  Professor 
James  Israel,  the  master  of 
renal  surgery. 

In  the  preparation  of 
his  classic  work  on  the  sur- 
gery of  the  kidney  he  has 
incorporated  his  vast  clin- 
ical material  and  has  laid 
down  rules  of  action  calcu- 
lated to  secure  the  best  re- 
sults. 

This  book  is  a  veritable 
mine  of  information  and 
should  be  translated  at  once 
into  the  English  language. 
It  is  safe  to  state  that  its 
author  has  had  more  expe- 
rience in  surgery  of  the 
kidney  than  any  other  surgeon.  There  are  a  number  of  serious 
and  obscure  questions  pertaining  to  the  surgery  of  this  organ 
he  has  definitely  settled.    He  very  naturally  demands  of  the 


Professor  James  Israel. 


surgeon  an  accurate  anatomic  knowledge  of  the  kidney  and  its 
environment.  He  very  correctly  asserts,  contrary  to  the 
opinion  generally  entertained,  that  of  all  kidney  operations 
nephrectomy  is  the  easiest.  He  strongly  advocates  conservative 
operations  whenever  compatible  wath  the  strnctural  changes 
which  have  taken  place.  He  emphasizes  the  importance  of 
exposing  the  organs  freely  in  all  operations,  so  that  the  surgeon 
can  make  a  thorough  examination,  upon  which  depends  final 
diagnosis  and  the  te(thnic  of  the  visceral  interference.  He 
insists  upon  catheterization  of  the  ureter  in  all  operations  upon 
the  pelvis  for  the  purpose  of  detecting  and  removing  mechani- 
cal obstructions.  He  is  satisfied  that  if  this  is  done  urinary 
fistula  never  occurs.  He  does  not  look  upon  ether  as  a  danger- 
ous anesthetic  in  renal  surgery.  The  local  effect  of  ether  on  the 
kidney  tissue  is  of  shorter  duration  than  of  chloroform. 

It  was  my  pleasure  to  witness  a  number  of  his  operations, 
which  I  will  describe  as  briefly  as  their  importance  permits  : 

Case  I. —  Lithiafiia  arid  Pyonephrosis^  of  Right  Kidney: 
Nephrotoiny.  The  patient  was  a  woman,  aged  35.  She  had 
lumbar  pain  in  the  right  side,  and  pyuria  for  several  years. 
Her  general  health  was  materially  impaired.  The  right  kidney 
was  the  size  of  a  cocoanut,  freely  movable.  Diagnosis  was  doubt- 
ful. Tuberculosis  had  been  excluded.  There  were  decided  symp- 
toms of  stone.  Ether  narcosis  was  obtained.  Long  transverse 
incision  was  made  revealing  first  preperiton<-al  fat,  next  retrore- 
nal  fascia,  and  lastly  the  kidupy  e^nveloped  by  its  adipose  cap- 
sule. The  preperitoneal  fat  and  retrorenal  capsule  were  incised 
vertically  toward  the  spinal  side  so  as  to  guard  against  opening 
the  yjeritoneal  cavity  when  these  structures  were  reflected  by 
the  use  of  fingers  and  sponge  pressure  until  the  hilus  of  the 
kidney  was  reached  and  the  ureter  was  freely  exposed.  The 
kidney  was  very  much  enlarged  and  uneven.  The  space 
around  the  kidney  was  packed  firmly  with  gauze  before  it  was 
in<;ised.  The  incision  was  made  on  the  convex  side,  from  p"le 
to  pole.  A.  large  quantity  of  fetid  pus  escaped  and  a  numl)er 
of  faceted  stones  were  removed.  Catheterization  of  the  ureter 
was  now  made.  The  operator  declared  that  it  is  exceedingly 
dirticult  and  often  impossible  to  find  the  ureteral  orifice  with- 
out exposure  of  the  ureter.  Traction  on  the  ureter  causes 
a  dimple  like  depression  on  the  surface  of  the  pelvis, 
the  deepest  portion  of  which  always  corresponds  Avith 
the  ureteral  inlet.  The  prolje  and  afterward  the  ureteral 
catheter  entered  the  bladder  without  difficulty.  Catheter- 
ization of  the  ureter  before  operation  revealed  blood  and  pus 
corpuscles  in  the  urine  from  the  opposite  kidney.  The 
calyxes  of  th«^  pelvis  were  freely  slit  opea  with  a  blunt-pointed 
bistoury,  and  after  thorough  flushing  all  of  the  depressions 
and  pelvis  wfre  packed  with  iodoform  gauze.  The  margins  of 
rhe  visceral  incrision  were  stitched  to  the  lumbar  muscles  and 
fascia  with  caterut.  A  copious  absorbent  dressing  was  applied. 
It  is  worthy  of  note  that  no  safety  pins  are  used.  A  long,  heavy 
silk  thread  is  tied  to  the  projecting  part  of  each  gauze  strip. 
The  finding  of  calculi  in  the  kidney  operated  upon,  points 
to  the  existence  of  a  similar  affection  in  the  opposite  organ.  The 


precisiou,  thoroughness  and  neatness  with  which  this  operation 
was  performed  would  have  pleased  the  most  critical  observer. 

Cask  II. — Hematuria .-  Exploratory  Incision.  The  patient 
was  a  woman  32  years  of  age,  anemic  and  obese.  For  a  number 
of  years  she  suffered  from  hematuria  of  renal  origin.  Ureteral 
catheterization  loi-ated  the  disease  in  the  right  kidney.  Patient 
appears  to  be  the  subject  of  a  hemorrhagic  disposition,  as  all 
wounds  have  always  bled  freely.  Ether  narcosis  was  obtained. 
Long  transverse  incision  was  made.  Subcutaneous  and  preperi- 
toneal fat  were  found  to  be  very  abundant.  Kidney  not  enlarged 
and  very  inaccessible.  Palpation  of  pelvis  was  negative.  A 
hard  mass  the  size  of  a  hazelnut,  above  the  kidney  and  in  close 
proximity  to  the  large  vessels,  was  discovered.  No  indications 
Avere  found  for  a  visceral  incision.  It  was  surmised  that  a 
malignant  tumor  in  the  pararenal  space  might  account  for  the 
hemorrhage  by  interfering  with  venous  circulation  by  com- 
pression.   The  incision  was  closed  by  deep  interrupted  sutures. 

Case  111.— Renal  Lithiasis:  Pyonephrosis;  Nephrotomy.  The 
patient  was  a  man,  aged  42;  premature  senility.  He  has  not 
been  well  since  he  was  operated  upon  for  stone  when  a  boy. 
Evidently  a  cystitis  developed  after  the  operation,  followed  l>y 
an  ascending  tireteritis,  which  culminated  in  pyelitis  and 
pyonephrosis.  There  were  no  symptoms  pointing  to  the  exist- 
ence of  a  renal  calculus.  A  long  transverse  incision  was  made, 
the  kidney  was  found  slightly  enlarged  and  firmly  adherent. 
The  intention  of  the  operator  was  to  make  a  nephrectomy,  but 
the  conditions  revealed  by  the  incision  made  such  a  procedure 
impossible.  When  the  kidney  was  incised  half  a  teacupful  of 
fetid  pus  escaped.  Digital  exploration  of  the  pelvis  of  the 
kidney  revealed  the  presence  of  a  number  of  small  stones,  which 
were  removed.  Catheterization  of  the  ureter  could  not  be 
made.  Suturing  of  visceral  incisions  to  lumbar  muscles  and 
fascia  was  done;  tubular  and  gauze  drainage.  The  external 
wound  was  diminished  in  size  by  a  few  deep  and  superficial 
sutures,  and  copious  dressing  of  absorbent  material  completed 
the  operation. 

Case  IV.— Chronic  Papillomatous  Cystitis;  Suprapubic  Cys- 
totomy. The  patient,  a  man  of  35  years,  was  well  nourished. 
Twenty  years  ago  he  was  operated  upon  for  stone  in  the  bladder 
by  crushiag.  Symptoms  of  cystitis  were  not  relieved.  Bladder 
is  very  small.  Two  years  ago  some  papillomatous  masses  were 
removed  per  urethra.  This  operation  gave  no  relief.  Tumor  of 
the  bladder  in  the  region  of  one  of  the  ureteral  orifices  is  sus- 
pected. At  no  time  was  there  hematuria  of  any  consequence. 
Urine  was  loaded  with  pits.  Bladder  was  inflated  with  air  and 
patient  placed  in  Trendelenburg's  position.  Transverse  incision 
severed  insertion  of  recti  muscles  almost  completely.  Bladder 
was  brought  well  forward  l3y  making  traction  on  two  silk  liga- 
tures and  incised  transversely.  Digital  exploration  revealed  a 
diffuse  papillomatous  condition  of  the  mucous  membrane. 
Urethral  drainage  was  done  by  the  use  of  a  soft  rubber  catheter 
with  vesical  end,  expanded  so  as  to  hold  the  instrument  in 
place.  The  vesical  wound  was  closed  by  two  rows  of  catgut 
sutures,  the  first  one  embracing  all  tissues  except  mucous  mem- 
brane, when  it  was  covered  by  a  second  row.  External  incision 
was  united  by  deep  silk  sutures  which  brought  the  divided 
muscles  in  accurate  approximatiou. 


[Reprinted  from  American  Medicine,  Vol.  IV,  No.  5,  pages  185-186, 
August  2,  19Cr2.] 


PROFESSOR  HOFFA'S  ORTHOPEDIC  WORK. 


NICHOLAS  SENN,  M.D., 
of  Chicago. 

Professor  Hoffa,  although  not  more  than  40  years  of  age, 
is  well  known  to  the  surgical  profession  by  his  clinical  work  and 
most  important  literary  contributions.  His  two  books  on 
"  Orthopedic  Surgery  "  and  "Fractures  and  Dislocations  "  have 
been  most  favorably  received  and  have  contributed  much  toward 
the  advancement  of  these  two  distinct  branches  of  surgery. 

Three    weeks    ago    he    came        

from  Wurz1)urg  to  till  the  va- 
cancy caused  by  the  recent 
death  of  Professor  Julius 
Wolff.  He  did  not  have  to 
wait  long  for  work.  His  pub- 
lic and  private  clinics  are 
crowded  with  patients.  Some 
idea  may  be  formed  of  the 
amount  of  his  clinical  mate- 
rial by  the  50  cases  of  congen- 
ital dislocation  of  the  hip- 
joint  which  are  now  under  his 
treatment.  I  was  given  an 
opportunity  to  see  20  cases  in 
the  Polyclinic  and  to  witness 
two  bloodless  reductions  in 
the  Polyclinic  in  one  after- 
noon. Thirty  cases  are  under 
treatment  in  ambulances.  The 
work  in  the  Polyclinic  begins  at  2  o'clock  and  continues 
incessantly  during  the  entire  afternoon.  A  trained  nurse  and 
a  staff  of  physicians  render  the  necessary  assistance.  Profes- 
sor Hoffa  is  an  orthopedic  surgeon  in  every  sense  of  the  word. 
His  knowledge  is  not  limited  to  mechanics;  he  operates  when- 
ever he  is  satisfied  that  in  doing  so  the  desired  result  can  ])e 
reached  in  a  shorter  time  and  to  a  greater  degree  of  perfection 
than  by  the  exclusive  reliance  on  mechanical  contrivances. 
Every  one  of  his  operations  demonstrates  an  intimate  knowl- 
edge of  anatomy  and  sound  surgical  sense.  Chloroform  is  used 
by  the  drop  method  as  an  anesthetic  and  silk  as  suturing  and 


Professor  A.  Hotfa. 


ligature  material.  Tae  silk  is  sterilize!  by  boiling  in  sub- 
limate solution.  Surface  disinfection  consists  in  thorough 
cleansing  by  mechanical  measures,  followed  by  sublimate  solu- 
tion and  alcohol.  The  name  of  Hoffa  came  prominently  before 
the  profession  by  the  bloody  operation  he  devised  for  the  reduc- 
tion of  congenital  dislocation  of  the  hip-joint.  A  large  experi- 
ence with  this  method  has  made  him  an  enthusiastic  advocate 
of  the  bloodless  method  as  described  and  practised  by  Pad. 
He  is,  however,  of  the  opinion  that  in  patients  more  than  8 
years  of  age  the  bloodless  method  seldom,  if  ever,  proves  suc- 
cessful. In  this  class  of  patients  he  continues  to  perform  his 
operations  with  excellent  results,  as  I  had  abundant  oppor- 
tunity to  ascertain.  In  his  private  clinic  a  patient  was  exhib- 
ited, operated  upon  seven  years  ago,  who  walked  without  a 
limp.  This  patient  was  one  of  the  first  operated  upon  by  the  open 
method.  In  children  less  than  8  years  of  age  he  always  gives 
the  bloodless  method  a  faithful  trial  before  he  resorts  to  the 
knife  and  chisel.  Several  patients,  one  among  them,  a  woman  of 
21,  recently  operated  upon,  were  doing  well.  The  operative 
work  of  one  afternoon  in  the  Polyclinic  included  two  cases  of 
bloodless  reduction  of  congenital  dislocation  of  the  hip-joint 
and  a  case  of  tendoplasty. 

Case  I. — Congenital  dislocation  of  left  hip-joint :  reduction  by 
bloodless  method.  The  patient,  a  girl,  between  three  and  four 
years,  had  a  congenital  dislocation  of  the  left  hip-joint  with  a 
moderate  degree  of  shortening.  When  fully  under  the  influence 
of  chloroform  the  patient  was  brought  into  proper  position  by 
bringing  the  pelvis  to  the  margin  of  the  table  and  resting  upon  a 
firm,  flat  pillow.  An  assistant  fixed  the  pelvis,  and  the  operator 
abducted  the  thigh  until  it  was  at  a  right  angle  with  the  pelvis. 
With  the  thumb  of  the  right  hand,  firm  pressure  was  made 
against  the  great  trochanter,  while  with  the  Uft  the  femur  was 
rotated  forcibly  outward.  These  movements  were  made  at  short 
intervals  and  soon  succeeded  in  lifting  the  head  uponthe  margin 
of  the  acetabulum,  when  during  the  next  manipulation  it 
slipped  into  the  depression  with  an  audible  snap.  The  bone  was 
again  dislocated  and  complete  reduction  effected  with  the  same 
ease.  The  limb  was  then  abducted  at  an  angle  of  45  degrees, 
strongly  rotated  outward  and  immobilized  in  a  circular  plaster- 
of-paris  splint,  which  included  the  pelvis  and  thigh.  During 
the  setting  of  the  plaster,  firm  pressure  was  made  against  the 
great  trochanter.  In  applying  the  splint,  the  child  was  first 
placed  in  the  ventral  position  ;  the  dressing  was  finished  in  the 
dorsal  position.  If  the  reduction  proves  successful,  the  splint 
remains  for  three  months.  The  splint  is  made  more  durable 
and  kept  clean  for  this  long  usage  by  coating  it  with  water-glass 
after  it  has  become  firm  and  dry.  In  this  case  a  perfect  result 
is  assured. 

Case  II. — Congenitfd  dislocation  of  the  hip-joint :  bloodless 
reduction  under  difficulties.  Boy,  of  "four  years,  presenting  a 
dislocation  of  the  "left  hip-joint  with  marked  shortening.  The 
iipper  border  of  the  great  trochanter  was  near  the  iliac  crest. 
Repeated  manipulations  failed  in  effecting  reduction.    The  con- 


traded  adductor  muscles  were  placed  on  the  stretch  and  were 
kneaded  to  overcome  their  resistance.  Traction  force  in  abduc- 
tion was  then  applied  on  both  limbs  with  an  apparatus,  the 
perineum  resting  against  an  upright.  The  persistent  strong 
traction,  aided  by  manual  pressure  against  the  great  tro- 
chanter, finally  succeeded  in  reducing  the  head  of  the  femur 
into  the  shallow  acetabulum.  Fixation  dressing  the  same  as  in 
the  first  case  was  applied  without  relaxing  the  traction,  "which 
was  continued  until  the  splint  became  firm.  Between  the 
splint  and  surface  a  smooth  layer  of  cotton  half  an  inch  in 
thickness  was  interspersed. 

Case  III.— Tendop I asty  for  infantile  paralysis  of  exten- 
sor and  supinator  muscles  of  the  forearm.  This  patient 
was  a  boy  of  12  years.  The  original  spinal  affection  para- 
lyzed both  limbs  on  the  right  side.  The  muscles  of  the 
lower  extremity  regained  function  sufficiently  so  that  the 
boy  can  walk  fairly  well.  Adductors  of  thigh  contracted 
with  resulting  adduction  of  thigh.  Subcutaneous  tenotomy, 
with  a  small  sickel-shaped  tenotome,  corrected  this  deformity 
at  once.  The  operation  upon  the  forearm  consisted  in  utilizing 
the  pronator  radii  teres. as  a  substitute  for  the  paralyzed  supi- 
nators, w^hich  was  accomplished  in  the  following  manner:  The 
arm  w^as  rendered  bloodless  by  elastic  constriction.  An  in- 
cision Sh  inches  in  length  was  made  over  the  pronator  radii 
teres  on  the  ulnar  side  from  its  point  of  origin  downward  and 
outward.  The  muscle  was  then  isolated  and  detached  from  the 
internal  condyle  of  the  humerus.  A  second  incision  about  tw^o 
inches  in  length  was  then  made  over  the  external  condyle,  and 
through  the  incisions  a  tunnel  was  made  with  blunt  instru- 
ments underneath  the  flexor  muscles,  through  which  the  free 
end  of  the  pronator  muscle  was  drawn  and  sutured  to  the 
external  condyle  wit*i  silk.  Hoffa  has  performed  this  opera- 
tion in  three  similar  cases  with  very  satisfactory  functional 
results.  The  second  operation  was  made  for  the  purpose  of 
making  use  of  the  flexor  carpi  radialis  and  ulnaris  muscles 
as  substitutes  for  the  paralyzed  extensor  muscles.  Through  a 
short  incision  the  tendons  of  these  muscles  were  isolated  and 
divided  immediately  above  the  wrist  joints.  The  tendon 
ends  were  at  once  secured  by  a  ligature.  The  next  step  of  the 
operation  exposed  the  extensor  tendons  by  a  median  dorsal 
incision  above  the  annular  ligament.  Through  a  slit  in  the 
tendon  sheath  the  tendon  ends,  drawn  through  the  subcuta- 
neous tunnels,  w^ere  stitched  with  five  silk  sutures  to  the 
tendons  and  tendon  sheath.  All  of  the  wounds  were  closed 
with  interrupted  silk  sutures  and  dressed  before  the  elastic 
constrictor  was  removed.  The  operations  were  performed 
with  a  neatness  and  accuracy  that  showed  a  perfect  familiarity 
with  the  anatomy  and  mechanics  of  the  muscles  concerned. 

Case  TV  .—Gonorrheal  synovitis  of  tlie  knee-joint :  irnrno- 
bilization  of  quadratus  extensor  femoris  muscle  :  tendoplasty. 
The  patient,  a  female  of  25  years,  had  a  gonorrheal  synovitis  of 
the  left  knee  which  resulted  in  fibrous  ankylosis  and  functional 
loss  of  the  extensor  femoris  muscle.  The  limb  w^as  nearly 
straight,  the  joint  fixed.  Several  attempts  had  been  made  to 
render  the  joint  movable  by  hrisement  force  under  a  general 
anesthetic  without  avail.  It  was  decided  to  use  two  of  the 
hamstring  muscles  as  a  substitute  for  the  extensor  muscle. 
The  biceps  and  the  semitendinous  were  selected.  Each  of  these 
tendons  was  exposed  by  a  short  incision  and  divided  near  the 
insertion  and  sutured  to  the  anterior  surface  of  the  patella  and 


on  each  side.  The  implautatiou  was  done  through  a  small  in- 
cision over  the  inner  and  outer  borders  of  the  patella.  The  ten- 
don ends  were  brought  through  a  subcutaneous  tunnel  from 
their  normal  location  to  their  new  destination.  The  operation 
was  performed  under  bloodless  constriction  and  the  four 
wounds  sutured  without  making  any  provision  for  drainage. 

The  next  patients  were  operated  upon  in  Hoffa's  private 
clinic,  16  Achenbach  street,  Charlottenburg.  The  building  is 
new  and  in  a  most  select  part  of  the  great  city.  It  was  built 
recently  for  this  express  purpose  at  an  expense  of  $150,000.  The 
interior  in  appearance  and  furnishing  resembles  a  private  house. 
It  can  accommodate  50  patients,  and  every  bed  is  occupied. 

A  well  equipped  inechanical  department  furnishes  the 
apparatuses,  most  of  which  are  designed  by  Hoffa.  The  hall  for 
gymnastic  exercise  is  a  revelation  to  the  visitor.  Massage  and 
electricity  are  applied  in  consonance  with  modern  scientific 
principles.  The  discipline  throughout  the  house  is  faultless. 
On  the  day  I  visited  this  institution  I  met  Professor  Xeuber,  of 
Kiel,  who  had  been  studying  Hoffa's  methods  for  more  than  a 
week.  This  one  circumstance  satisfied  me  that  I  was  in  the 
house  of  a  master.  A  visit  through  the  private  rooms  and  small 
wards  satisfied  me  what  skill  can  do  to  benefit  crippled  human- 
ity. Paralyzed  extremities  were  made  useful  by  tendoplasty  or 
by  the  use  of  mechanical  appliances.  Patients  that  never 
walked  had  abandoned  all  mechanic  supports,  and  were  practis- 
ing muscles  that  were  made  to  take  the  place  of  others  that 
had  become  useless. 

Case  V. — Calcaneo-valgus ;  tendoplasty.  This  patient  was 
a  girl  of  10  years,  with  infantile  paralysis,  which  resulted  in 
slight  calcaneus  and  marked  valgus  deformity.  The  muscles 
of  the  leg  were  decidedly  atrophied.  The  defective  muscles 
were  strengthened  or  their  functional  loss  was  restored  by 
tendoplasty.  An  incision  w^as  made  over  the  tendo-Achillis 
as  far  as  its  insertion  into  the  os  calcis.  The  tendon  was 
divided  in  the  center  anteroposteriorly  and  the  inner  half 
severed  from  its  insertion.  An  incision  was  then  made  over 
the  tibialis  posticus  tendon.  This  tendon  was  very  small  and 
abnormally  long.  About  three  inches  of  this  tendon  were 
doubled  by  a  double  purse-string  suture  of  fine  silk  and  the 
base  of  the  duplicated  part  ligated  loosely  with  the  same  ma- 
terial. Through  a  subcutaneous  tunnel  \he  tibial  part  of  the 
tendo-Achillis  was  connected  with  the  shortened  tibialis  posti- 
cus or  by  a  number  of  fine  silk  sutures.  The  next  step  of  the 
operation  consisted  in  utilizing  the  peroneus  brevis  to  invert 
the  foot.  This  was  done  by  first  making  an  incision  over  the 
peroneal  tendons  behind  the  posterior  border  of  the  external 
malleolus.  The  pei-oneus  brevis  was  severed  and  the  remain- 
ing peroneal  tendon  which  had  become  dislocated  forward 
was  replaced  and  fastened  in  its  shallow  groove  by  four  fine 
silk  sutures.  The  internal  surface  of  the  os  calcis  was  then  ex- 
posed by  a  short  incision.  The  cut  end  of  the  tendon  of  the 
peroneus  brevis  was  then  drawn  through  a  tunnel  behind  what 
remained  of  the  tendo-Achiliis  and  sutured  to  the  periosteum 


of  the  internal  surface  of  the  os  calcis  with  four  tine  silk  sutures. 
The  uncut  part  of  the  tendo-Achillis  was  then  shortened  by 
suturing.  All  of  the  wounds  were  sutured  with  the  same  ma- 
terial and  included  in  the  same  dressing. 

I  was  given  an  opportunity  to  examine  many  cases  of  teu- 
doplasty  for  most  diverse  paralytic  affections  of  the  foot,  arm 
and  hand  with  marvelous  functional  results,  cases  which  but 
a  few  years  ago  would  have  been  pronounced  hopeless.  In 
aggravated  cases  of  equinovarus  the  tendo-Achillis  is  elongated 
and  the  tibialis  posticus  is  used  as  a  substitute  for  the  extensor 
muscles  by  implantation  of  its  tendon  into  the  common  tendon 
of  the  extensors  above  the  ankle-joint.  The  cut  tendon  of  the 
tibialis  posticus  is  drawn  through  a  subcutaneous  tunnel  and 
securely  sutured  to  the  extensor  tendons  and  their  sheath.  The 
elongated  tendons  are  shortened  at  the  same  time  by  duplica- 
tion. Tendoplasty  as  practised  by  Professor  Hoffa  marks  a 
new  era  in  orthopedic  surgery  and  when  once  fully  understood 
and  generally  practised  by  surgeons  will  become  the  means  of 
restoring  many  helpless  limbs  to  usefulness  and  will  become  a 
source  of  great  regret  to  the  mercenary  instrument  makers. 
Berlin,  May  27. 


[Reprinted  from  American  Medicine,  Vol.  IV,  No.  5,  pages  186-187, 
August  2,  1902.] 


PROFESSOR  SONNENBURG  AND  HIS  APPENDICITIS 
WORK  AT  THE  MOABIT  HOSPITAL. 


NICHOLAS  SENN,  M.D., 
of  Chicago. 
Every  general  surgeon  sooner  or  later  excels  in  some 
special  branch  of  his  profession.  Nowhere  is  the  truth  of  this 
statement  more  clearly  sliown  than  in  Berlin.  In  brain  sur- 
gery von  Bergmann  is  the  acknowledged  authority.  Konig 
is  the  master  in  diseases  of  bones  and  joints.  Hahn  has  no 
superior  in  surgery  of  the  gastrointestinal  canal.  Israel  has  a 
w^ell-earned  reputation  in  renal  surgery.  Krause  leads  in  sur- 
gery of  the  nerves,  and  lastly,  Sonnenburg  speaks  the  last  and 
decisive  word  when  the  subject  of  appendicitis  is  discussed. 
These  are  all  general  surgeons  who  can  and  do  perform  any 
operation  in  surgery,  but  their  reputation  at  home  and  abroad 
is  largely  due  to  what  they  have  accomplished  in  the  branch  of 
their  profession  which  they  have  made  the  subject  of  special 
study  and  investigation.  Sonnenburg,  the  most  gifted  assistant 
of  the  late  Professor  Luecke,  of  Strasburg,  is  one  of  the  busiest 
men  in  Berlin.  His  private  clinic  is  large,  and  at  the  Moabit 
Hospital  he  is  in  charge  of  350  beds.  He  is  a  thorough  scholar 
and  speaks  several  languages  fluently.  His  contributions  to 
surgical  literature  are  numerous,  but  the  climax  of  his  literary 

career  was  reached  with  the 
publication  of  his  book  on  ap- 
pendicitis. This  classic  mono- 
graph has,  in  a  short  time, 
reached  the  fourth  edition, 
the  best  proof  of  its  well- 
merited  popularity.  The 
value  of  this  book  is  to  be 
found  in  the  manner  in  which 
the  pathologic  conditions  of 
the  various  forms  of  appendi- 
citis are  discussed  and  the  logi- 
cal deductions  drawn  there- 
from, as  w^ell  as  in  the  accuracy 
with  which  the  complicated 
cases  are  described.  Last  win- 
ter the  number  of  patients  he 
has  operated  upon  reached 


Professor  Sonnenburg. 


1,0(X).  The  internes  in  his  serv- 


ice  at  the  Moabit  celebrated  this  event  in  an  appropriate  manner 
witli  their  chief.  At  present  tliere  are  15  patients  in  tliis  hospital 
who  were  recently  operated  npon  for  appendicitis.  Three  opera- 
tions a  day  is  not  an  uncommon  occnrrence.  The  entire  mortal- 
ity of  the  1,000  cases  was  12%,  and  of  the  cases  operated  upon  dur- 
ing the  interval  only  1%.  Grave  symptoms  during  the  first  24 
hours  of  the  attack  are  looked  upon  as  strongly  suggestive  of 
gangrene,  and  it  is  in  such  cases  that  an  operation  is  performed 
with  the  least  possible  delay.  In  the  absence  of  positive  indica- 
tions for  immediate  action,  it  is  deemed  advisable  to  operate  dur- 
ing the  interval.  In  all  pus  cases  the  cavity  is  drained  with  a 
Mikulicz  tampon  and  the  wound  allowed  to  heal  by  granulation. 
The  gradual  removal  of  the  gauze  drain  employed  in  this 
manner  can  be  done  with  greater  ease  and  is  productive  of  less 
pain  than  when  the  abscess  cavity  is  packed  with  separate 
strips  of  gauze.  In  amputating  the  appendix  a  transfixion 
double  ligature  is  used.  The  mucous  membrane  of  the  stump 
is  not  cauterized  and  the  stump  is  buried  by  two  rows  of 
catgut  sutures.  The  first  row  of  sutures  embraces  all  of  the 
coats  of  the  cecum,  contrary  to  the  usual  practice.  Before 
making  the  incision  an  assistant  draws  the  skin  two  to  three 
inches  toward  the  median  line  for  the  purpose  of  securing  for 
the  muscular  part  of  the  wound  and  the  subsequent  line  of 
union  a  covering  of  normal  -skin.  Whenever  practicable  the 
muscle  splitting  incision  is  made.  If  the  incision  is  sutured,  as 
is  always  done  when  no  pus  is  found,  catgut  is  used  for  the  peri- 
toneum, silk  for  the  muscles  and  fascia,  and  bronze  aluminium 
wire  for  the  skin.  The  wire  is  very  flexible  and  does  not  irri- 
tate the  tissues.  A  small  absorbent  pad  held  in  place  by  a 
gauze  bandage  constitutes  the  dressing.  Irrigation  is  not  used 
in  pus  cases. 

The  Moabit  Hospital  accommodates  950 patients.  It  is  made 
up  of  a  village  of  35  pavilions  and  administrative  buildings. 
The  space  included  by  the  buildings  is  a  large  square  beauti- 
fully laid  out,  with  a  macadamized  street  and  walks,  and  orna- 
mented with  exquisite  flowers  and  blooming  shrubs.  Two  of 
the  pavilions  are  used  exclusively  for  emergency  cases.  The 
two  operating  rooms  are  modern  and  contain  the  most  com- 
plete outfit  of  surgical  instruments  I  have  ever  seen  in  any 
hospital.  Trained  male  and  female  nurses  take  care  of  the  sick. 
In  the  operating  room  the  necessary  assistance  is  rendered  by 
four  salaried  internes,  two  orderlies  and  a  female  nurse.  The 
orderlies  take  care  of  instruments,  ligature  and  suture  material ; 
the  female  nurse  hands  the  gauze  sponges. 

The  catgut  used  in  the  operations  is  prepared  by  Saul's 
method  of  sterilization.  A  large  experience  has  proved  this  to 
be  reliable. 


SAUL'S   METHOD   OF   CATGUT   STERILIZATION. 

Immerse  and  boil  the  catgut,  which  has  been  deprived  of 
all  fatty  material,  in  the  following  solution  : 

Absolute  alcohol 1,700  parts 

Carbolic  acid 100  parts 

Distilled  water 200  parts 

Preserve  in  same  solution  in  sealed  bottles  of  convenient  size. 

THREE   CASES   OF   APPENDICITIS. 

Case  I. — Perforative  appendicitis ;  circnimscribed  supjinra- 
tive  peritonitis.  The  patient  is  a  female,  aged  56,  who  is  suffer- 
ing from  a  first  attack.  She  was  taken  three  days  ago  with 
violent  initial  symptoms.  There  was  vomiting  and  character- 
istic pain.  Temperature  was  102°  F.,  the  pulse  was  120  and 
small.  Facial  expression  and  muscular  rigidity  indicated  quite 
extensive  peritonitis.  There  is  some  dulness  in  the  right  iliac 
fossa  beneath  the  distended  cecum.  Operation  was  done  by  Dr. 
Hermes,  first  assistant.  The  incision  was  made  very  close  to 
the  crest  of  the  ilium  and  Poupart's  ligament.  The  perito- 
neum was  reflected  and  when  the  posterior  surface  of  the  cecum 
was  reached  several  tablespoonfuls  of  fetid  pus  escaped.  In  the 
abscess  cavity  a  fecal  stone  was  found.  The  perforation  was  in 
the  middle  of  the  appendix,  and  the  distal  end  was  gangrenous. 
The  mesenteriolum  was  tied  in  several  sections,  the  appendix 
ligated  at  its  base  and  amputated.  The  stump  was  buried  by 
two  rows  of  catgut  stitches,  the  first  including  the  entire  thick- 
ness of  the  cecal  wall.  The  cavity  was  packed  with  a  Miku- 
licz drain. 

The  day  after  the  operation  all  of  the  grave  symptoms  had 
subsided,  and  unless  new  complications  arise  a  speedy  recovery 
is  predicted. 

The  Mikulicz  drain  is  always  used  in  pus  cases.  The 
wound  is  left  open  and  heals  by  granulation.  If  a  hernia  de- 
velops in  such  cases,  as  not  infrequently  happens,  a  radical 
operation  is  performed. 

The  next  two  cases  were  operated  upon  by  Professor  Son- 
nenburg  the  same  forenoon. 

In  making  the  incision  he  draws  the  skin  toward  the  median 
line  so  as  to  cover  the  muscular  wound  with  normal  skin.  In 
doing  so  the  skin  sutures  and  the  resulting  scar  are  placed  ex- 
ternal to  the  anterior  superior  spinous  process  of  the  ilium.  In 
pus  cases  a  free  long  incision  is  made ;  in  relapsing  cases  with- 
out abscess  formation,  the  muscle  splitting  method  is  employed. 
In  the  latter  class  of  cases  the  patients  are  confined  to  bed 
from  two  to  three  weeks. 

Case  II. — Relai)sing  appendicitis  :  extensive  retrocecal  ad- 
hesions. The  patient  had  three  attacks,  the  first  one  being  most 
severe.  He  was  a  young  man  who  was  otherwise  in  good 
health.  The  first  attack  occurred  a  year  ago,  the  last  one  re- 
cently. Through  a  comparatively  short  incision  the  attached 
end  of  the  appendix  was  found.  A  double  catgut  ligature  was 
applied  and  the  appendix  divided  between.  The  ligature  on 
the  appendix  was  used  in  carefully  dragging  the  appendix 


toward  the  wouud.  The  appendix  was  long  and  imbedded  in 
its  entire  length  in  a  mass  of  adhesions,  and  much  of  it  had  to 
V)e  removed  by  subserous  enucleation.  Several  other  traction 
ligatures  were  applied  during  the  process  of  enucleation.  The 
mesoappendix  was  ligated  in  several  sections.  The  stump  of 
the  appendix  was  buried  by  two  rows  of  sutures,  the  tirst  one 
including  the  entire  thickness  of  the  cecal  wall.  Peritoneum 
was  sutured  with  catgut,  muscles  and  fascia  with  silk  sutures, 
and  the  skin  Mith  bronze  aluminium  wire.  A  small  absorbent 
pad  constituted  the  dressing. 

Case  III. — Subacute  appendicitis;  duration  of  disease  two 
months:  operation.  The  patient  was  a  woman  advanced  in  years. 
The  attack  commenced  two  months  ago  without  any  abate- 
ment of  symptoms  since.  Continuous  high  temperature,  a 
rapid  feeble  pulse,  pains  in  the  ileocecal  region  and  progressive 
emaciation  were  the  most  prominent  symptoms.  The  abdom- 
inal wall  was  relaxed  and  there  was  no  palpable  swelling.  The 
abdomen  was  opened  in  the  same  manner.  The  appendix  was 
small  and  there  were  no  adhesions. 

It  was  explained  that  there  are  cases  in  which  the  extent  of 
the  local  disease  does  not  correspond  with  the  gravity  of  the 
general  symptoms. 

Professor  Sonnenburg  is  a  very  deliberate,  neat  and  dexter- 
ous operator  and  a  fluent  speaker.  He  possesses  all  of  the 
qualifications  which  make  a  clear  and  impressive  clinical 
teacher.  During  the  same  forenoon  he  operated  on  a  patient 
with  carcinoma  of  the  stomach. 

Case  IV. — Extensive  carcinoma  of  pylorus  with  diffuse  infil- 
tration of  retroperitoneal  glands;  gastroenterostomy.  The 
patient  was  a  woman  62  years  old.  Pyloric  obstruction  Avas 
almost  complete.  Incision  was  made  through  the  middle  of 
the  left  rectus  muscle.  The  mesentery  of  the  transverse  colon 
and  posterior  wall  of  the  stomach  near  the  cardiac  side  were 
translixed  with  a  strong  silk  ligature  and  after  making  a  button- 
hole in  the  latter  the  stomach  was  united  with  the  upper  part 
of  the  jejunum  with  a  large  Murphy  button.  A  few  Lembert 
sutures  were  applied  over  the  margin  of  the  button  as  an  addi- 
tional security.  Sonnenburg  thinks  well  of  the  Murphy  button 
in  performing  gastroenterostomy.  The  whole  operation  was 
completed  in  less  than  20  minutes. 

Berlin,  May  28. 


[Reprinted  from  American  Medicine.  Vol.  IV,  No.  7,  page  268, 
August  16,  1902.] 


THE  SEVENTH  CONFERENCE  OF  THE  INTERNA- 
TIONAL RED  CROSS 

BY 

NICHOLAS  SENN,  M.D., 

of  Chicago. 

Delegate  from  the  United  States. 

The  International  Red  Cross  Society  has  for  its  principal 
objects    to    render  war,    when    it   becomes    inevitable,    more 
humane  and  to  provide  prompt  relief  in  case  of  great  national 
calamities.    The  horrors  of  Sebastopol,  Gettysburg,  Solferino, 
Waterloo,  Sedan  and  other  great  battles  during  the  present  cen- 
tury will  have  no  equal  in  the  future.    Ignominious  death  from 
cold,  starvation  and  preventable  diseases  will  not  figure  so 
conspicuously  in  the  mortuary  records  of  future  wars  as  they 
have  done  in  the  past.   Governments 
and  nations  are  beginning  to  realize 
more  fully  the  importance  of  pro- 
viding   the   soldier  with    food   and 
clothing  conducive  to  the  preserva- 
tion of  his  health  and  bringing  into 
effective  action  sanitary  rules  and 
regulations  calculated    to  guard 
against  preventable  diseases.      The 
government  is  not  always  ready  and 
prepared  to  meet  sudden  emergen- 
cies.  The  representatives  of  the  Red 
Cross  Societies  are.    They  follow  the 
moving  armies,  take  care  of  the  sick 
''?U";'mTn'a!"ffi''^,1i^l"S  »<»  ^■^"''ded  and  distribute  freely 
the   Red  Cross  Society  of  food    and    drink    for    the    sick   and 
ConfeJenc'l'^  of^lhf ''inte?-  ^^'^^^les  of  comfort  not  obtainable  in 
national  Red  Cross.  any  other  way. 

In  great  epidemics,  devastating 
floods,  destructive  earthquakes,  sweeping  conflagrations  and 
burning  drouths,  they  are  the  first  to  reach  the  seat  of  disaster 
to  provide  the  unfortunates  with  shelter,  clothing  and  food.  The 
gospel  of  humanitarian  warfare  was  conceived  by  Henry 
Dunant,  of  Geneva,  Switzerland,  during  and  after  the  battle  of 
Solferino,  and  was  fully  expounded  in  his  now  famous  pam- 
phlet, "  Souvenir  de  Solferino."  His  suggestions  to  militate  the 
horrors  of  war  laid  the  foundation  for  the  proceedings  of  the 


Geneva  convention,  which  met  April  22, 1864.  The  International 
Red  Cross  Society,  the  precious  fruit  of  the  Geneva  convention, 
has  now  its  representative  organizations  in  all  parts  of  the  civil- 
ized globe,  and  is  the  pioneer  agency  in  disposing  of  the  bar- 
barities and  unnecessary  cruelties  of  active  warfare,  and  in 
bringing  prompt  aid  to  the  sufferers  of  great  national  calami- 
ties. The  growth  of  this  society  has  been  phenomenal.  From 
the  transactions  during  the  present  conference  it  is  evident 
that  this  great  international  Samaritan  is  desirous  of  cultivat- 
ing closer  relationships  between  National  Red  Cross 
Societies  and  to  extend  the  scope  of  humanitarian  work. 
The  International  Red  Cross  Society  meets  every  five  years, 
and  is  made  up  of  delegates  sent  by  governments  and 
representatives  of  Red  Cross  Societies,  the  traveling  expenses 
of  the  official  delegates  being  paid  by  the  respective  govern- 
ments. Some  of  the  Red  Cross  Societies  do  the  same  for  their 
representatives.  The  delegates  appointed  by  the  Russian  gov- 
ernment were  all  military  officers  of  high  rank  and  important 
government  officials.  The  only  female  delegates  are  from  the 
United  States.  The  names  of  the  delegates  embrace  20  different 
countries  and  various  local  organizations. 

All  of  the  meetings  are  held  in  the  Hall  of  Xobility,  a 
palatial  building  used  for  the  entertainment  of  the  nobility. 
On  this  occasion  it  was  tastefully  decorated  with  flowers  and 
shrubs.  Lieuteuanl-General  von  Richter  presided,  and  Mr. 
Odier  occupied  the  desk  of  the  secretary-general.  The  audience 
was  a  brilliant  one.  The  full-dress  uniforms  of  the  nobility, 
military  officers  and  high  government  officials  made  an  impos- 
ing and  enchanting  picture.  The  weather  was  in  harmony  with 
the  objects  of  the  meeting.  A  few  minutes  after  2  o'clock  the 
audience  rose  in  a  body  as  Her  Majesty,  the  Empress  Dowager 
Marie  Feodorovna  entered  the  hall  accompanied  by  her  son,  the 
Grand  Duke  Heritier  Michel  Alexandrovitch.  As  soon  as 
these  distinguished  members  of  the  royal  family  had  taken 
their  places  in  the  Imperial  box  the  president  opened  the  meet- 
ing with  a  short  address.  The  Minister  of  Justice,  Mouravieff, 
made  the  principal  speech,  in  which  he  emphasized  the  impor- 
tance of  the  Red  Cross  work  in  the  dispensation  of  charity,  and 
extended  a  cordial  welcome  to  the  delegates.  Yon  Knesebeck 
and  Schjerning  followed  with  short  speeches,  and  the  first 
meeting  was  adjourned. 

The  program  Avas  varied  and  the  reports  of  the  numerous 
committees  were  very  interesting.  The  discussions  were  char- 
acterized by  harmony  and  good  feeling.  Articles  of  the  Hague 
Peace  Convention  were  frequently  referred  to,  and  from  the 
remarks  made  it  is  certain  that  those  two  great  international 
organizations  will  cooperate  heartily  in  maintaining  the  peace 


of  the  world,  and  in  case  of  war  they  will  do  all  in  their  power  to 
divest  it  of  all  unnecessary  cruelties  and  suffering. 

Russian  hospitality  is  almost  proverbial.  The  Moscow 
International  Medical  Congress  gave  the  visiting  doctors  a 
good  insight  into  what  Russians  can  do  when  they  entertain 
their  guests.  If  there  is  any  fault  to  be  found  with  the  Seventh 
Conference  of  the  International  Red  Cross  it  is  the  fact  that  too 


ralace  where  Emperor  and  Empress  received  the  delegates. 

much  time  was  lost  in  entertaining  the  delegates.  Carriages 
were  placed  at  the  disposal  of  the  delegates  from  the  moment 
they  entered  the  city,  free  of  expense.  The  Central  Russian 
Committee  looked  after  the  comfort  of  each  delegate.  The 
principal  entertainments  were : 

1.  Informal  reunion  the  first  evening. 

2.  Banquet  at  the  Tauride  Palace,  second  evening,  at  which 
plates  were  set  for  250  guests. 

3.  Third  evening.  Steamer  excursions  on  the  Neva,  followed 
by  lunch  at  the  Zelaguine  Palace. 

4.  Reception  by  the  Empress  Dowager  at  the  Gatchina  Pal- 
ace, Saturday,  May  81. 

5.  Monday,  June  2.  Reception  by  the  Emperor  and 
Empress  at  the  Tzarkoe  S61o  Palace,  followed  by  lunch. 

6.  Sunday  evening.    Theater  and  concert. 

7.  Monday  evening.  Reception  by  the  mayor  at  the  City 
Hall. 

8.  At  the  close  of  the  session,  Wednesday,  June  4,  excur- 
sion to  Moscow. 

The  conference  was  in  session  a  whole  week  and  the  meet- 
ings were  well  attended.  The  French  language  is  the  official 
one,  although  the  German  and  English  languages  are  recog- 
nized.   The  transactions  are  published  in  French. 

St.  Petersburg,  June  3. 


[Heprinted  from  American  M'^dicine,  Vol.  IV,  No.  8,  pages  305-306, 
August  23,  1902.] 


THE  PIROGOFF  MUSEUM,  ST.  PETERSBURG. 

BY 

NICHOLAS  SENN,  M.D., 
of  Chicago, 

The  name  of  Nicholas  Pirogoff  stands  out  preeminently  in 
the  medical  history  of  Russia.  As  a  military  surgeon  he  had 
no  superior.  He  was  to  General  Todleben,  of  Crimean  fame, 
what  Baron  Larrey  was  to  Napoleon  Bonaparte.  Pirogoff's 
surgical  work  was  fully  appreciated  by  his  contemporaries,  and 
his  devotion  to  the  sick  and  wounded  of  the  Crimean  war  made 
him  the  idol  of  the  soldiers  and  the  recipient  of  the  gratitude  of 
a  great  nation.  His  vast  military  experience,  his  keen  powers 
of  observation  and  his  unquenchable  thirst  for  something  new 
and  better,  placed  him  in  a  position  to  speak  and  write  authori- 
tatively on  everything  pertaining  to  military  surgery.  His 
classic  work  on  this  subject  was  translated  into  nearly  all 
living  languages,  and  is  to  be  found  in  all  medical  libraries 
of  any  pretension.  It  can  be  read  with  interest  and  profit 
by  the  students  and  surgeons  of  today.  His-  description 
of  hospital  gangrene,  sepsis,  and  pyemia  as  he  saw  and  studied 
these  messengers  of  death  in  camp  and  field  make  a  pen  picture 
perfect  in  every  detail  and  which,  when  studied  with  the  nec- 
essary care,  reflects  the  darkest  part  of  the  angry  war  clouds 
which  hovered  over  and  about  Sebastopol  during  the  memor- 
able years  of  1854  and  1855.  His  accounts  of  the  immediate  and 
remote  effects  of  the  large  caliber  bullets,  shrapnel  and  frag- 
ments of  exploded  shells  were  based  on  careful  observations 
and  a  thorough  study  of  an  immense  clinical  material.  The 
conclusions  he  reached  were  fully  verified  by  the  experiences 
of  our  surgeons  during  the  great  Civil  war.  Pirogoff  was  a  pro- 
gressive surgeon  and  a  true  humanitarian.  The  great  personal 
sacrifices  he  made  for  the  defenders  of  his  country  live  in  the 
memory  of  a  grateful  nation.  His  name  is  a  household  word 
throughout  Russia.  The  medical  profession  reveres  and  honors 
his  memory.  Busts  in  snow  white  marble  and  durable  bronze 
immortalize  the  thoughtful,  kindly  face  of  the  distinguished 
dead  in  all  places  where  medicine  is  taught  in  Russia  to  remind 
students  of  what  he  did  for  his  country  and  the  science  and  art 
of  surgery. 

What  a  pity  that  a  man  who  spent  his  whole  lifetime  in 
relieving  suflfering  humanity  should  die  of  one  of  the  most 
cruel  of  all  diseases !   This  was  the  fate  of  poor  Pirogoff.    When 


advanced  in  years  and  when  his  task  on  earth  was  nearly  fin- 
ished, he  became  the  victim  of  carcinoma  of  the  upper  ja\v. 
The  disease  pursued  a  slow  course.  The  unfortunate  patient, 
who  had  dealt  with  this  disease  so  often  with  scalpel  and  caus- 
tics, visited  Professor  Billroth  and  begged  to  be  given  the 
l)enefits  of  radical  operation.  Pirogoff  then  was  82  years 
of  age.  The  great  surgeon  whose  services  he  sought 
weighed  the  evidences  for  and  against  an  operation  well 
and  with  tears  in  his  eyes  revealed  to  his  distinguished  col- 
league the  hopelessness  of  his  condition.  Pirogoff  returned  to 
St.  Petersburg  discouraged,  but  resigned  to  the  inevitable.  He 
was  met  at  the  station  by  an  enormous  crowd  of  admiring, 
sympathizing  colleagues  and  friends,  and  a  host  of  grateful 
soldiers  and  patients.  Soon  after  his  return  death  came  to  his 
relief,  and  his  noble  soul  departed  from  the  mould  of  clay  that 
was  disfigured  by  the  relentless  disease.  St.  Petersburg  has 
honored  the  memory  of  Pirogoff  in  a  most  worthy  manner  by 
establishing  and  maintaining  a  museum  known  as  the  Pirogoff 
Museum.  This  is  a  handsome,  solid  square  building,  two 
stories  high,  in  the  immediate  vicinity  of  the  Imperial  Military 
Academy,  separated  from  it  by  a  narrow  street.  The  building 
w^as  originally  a  storehouse  for  army  supplies,  and  was  pre- 
sented by  the  War  Department  to  the  medical  profession  of 
St.  Petersburg  for  this  special  purpose,  a  well  deserved 
and  gracious  recognition  on  part  of  the  government  of 
the  valuable  services  rendered  by  the  distinguished  dead 
to  his  country  and  his  profession.  The  building  has  been 
thoroughly  renovated  and  serves  at  the  same  time  as  a  meeting 
place  for  all  of  the  medical  societies  of  St.  Petersburg.  On  the 
first  floor  is  a  hall  with  300  to  400  seats  for  the  general  meetings. 
The  next  room  on  the  same  floor  and  communicating  with  the 
assembly  hall  is  the  museum  proper.  The  collection  contains 
some  very  interesting  and  rare  specimens  and  historic  surgical 
instruments.  The  surgical  instruments  used  by  Pirogoff  dur- 
ing the  Crimean  war  occupy  a  very  prominent  place  in  the 
last-named  department.  A  velvet-lined  pocket  case  Avith  old- 
fashioned  scalpels,  scissors,  etc.,  shows  the  wear  and  tear  of 
that  memorable  campaign.  In  a  separate  glass  case  is  exhib- 
ited a  part  of  the  tumor  preserved  in  alcohol  and  a  microscopic 
section  of  the  same  which  terminated  the  life  of  the  famous 
military  surgeon.  A  fine  portrait  in  oil  and  a  marble  bust 
reminds  one  of  the  name  of  the  place  they  are  in  and  a  photo- 
graph of  the  deathbed  with  the  lifeless  remains  shows  only  too 
plainly  the  ravages  of  the  fatal  disease.  The  first  floor  also  con- 
tains a  nucleus  for  a  general  medical  library.  The  second  floor 
is  devoted  to  the  different  specialties  in  medicine,  each  of  which 
has  its  own  room  and  library.   For  the  maintenance  of  this  ideal 


Bnedical  institution  the  members  of  the  different  medical 
•societies  pay  ten  rubles  (|5.00)  annually.  The  Pirogoff  Museum 
is  an  ideal  home  for  the  medical  profession,  containing  as  it 
does  a  rich  museum,  a  hall  for  general  meetings,  and  all  that 
€Ould  be  desired  for  the  different  specialties  in  medicine,  with 
-general and  special  libraries.  The  physicians  in  Cnicago  and 
in  other  large  cities  in  -our  country  have  for  years  labored  in 
vain  to  establish  a  somewhat  similar  institution.  Here  in  St. 
Petersburg  is  an  object  lesson  which  if  applied  to  our  conditions 
might  solve  many  difficulties  we  have  had  to  contend  with  in 
the  past.  On  my  way  from  Moscow  to  Constantinople  I 
remained  long  enough  at  Sebastopol  to  visit  the  battlefields 
where  Pirogoff  made  his  international  reputation.  Every 
schoolboy  is  familiar  with  the  stirring  events  that  made  Europe 
tremble  in  1854  and  1855.  Only  a  very  few  of  the  participants  of 
that  bloody  drama  remain  to  relate  the  sufferings  and  priva- 
tions of  that  eventful  campaign  so  devoid  of  i)ractical  results. 

The  valiant  charge  in  the  valley  of  Balaklava  and  the  stub- 
born struggles  on  the  plains  of  Inkermanu  were  events  that 
stand  out  prominently  in  the  history  of  the  middle  of  the  nine- 
teenth century.  The  Russians  held  the  eminence  behind  the 
invincible  harbor  of  Sebastopol,  and  within  a  thousand  yards 
of  their  line  of  battle  the  English  occupied  the  great  Redau 
(Greenhill)  supi)orted  by  the  French  on  the  right  and  on  the 
left.  The  plain  of  Inkermann  remains  today  much  the  same 
as  it  was  when  the  contending  forces  left  it— a  series  of  entrench- 
ments. A  railway  track  between  the  headquarters  of  the  Eng- 
lish army  and  the  city  of  Inkermann  could  be  used  today 
without  much  alteration  as  a  roadbed  for  a  modern  railway.  The 
English  fleet  finally  landed  at  Balaklava,  and  from  that  little 
seaport  town,  nine  miles  from  Sebastopol,  the  army  attacked 
the  Russians  on  the  left  flank,  with  the  disastrous  result  so 
familiar  in  history.  The  battlefield  of  Balaklava  is  now  cov- 
ered with  fertile  vineyards  and  peaceful  happy  homes.  The 
large  and  well-kept  Eaglish,  French  and  Russian  cemeteries 
contain  the  remains  or  memorial  slabs  of  over  200,000 
who  lost  their  lives  in  the  defense  of  the  cause  they 
represented.  In  riding  over  the  stony,  sterile  plains  of 
Inkermann  I  found  a  number  of  men  here  and  there 
plying  the  pickaxe  and  shovel  in  search  of  war  relics.  For 
nearly  50  years  this  strange  industry  has  been  a  source  of  con- 
siderable income  and  it  is  by  no  means  exhausted.  Cannon- 
balls,  bullets,  shrapnel,  fragments  of  exploded  shells,  buttons, 
buckles  and  rusty  horseshoes  are  brought  to  the  surface  daily 
and  are  sold  to  the  visitors  for  what  they  are  willing  to  pay.  On 
the  summit  of  the  Redau  is  a  handsome  monument  erected  by 
the  English  army  to  the  memory  of  the  fallen  heroes.    In  the 


office  of  the  English  cemetei-y  is  a  complete  list  of  all  the  rrames 
of  the  British  dead,  and  I  noticed  it  contained  the  names  of  an? 
Hnusually  large  number  of  surgeons.      This  can  \ye  readily 
explained  by  considering  the  causes  of  death.     It  is  well  knowEs 
that  the  great  mortality  of  the  allies  was  due  largely  to  acute- 
infe^'tious  diseases.      Cholera,   dysentery  and  camp  diarrhea, 
decimated    the     ranks     rapidly,    which    in    connection    with 
inadequate    clothing    and    food     supply,    contributed    much 
to    the     failure     of     the     campaign.      Tlie     Russian     army 
met    a    similar    fate.      Pirogoff    saw    moi-e    a-'tual    suffering- 
than    any    other    militai-y    surgeon    in    the    same   length    of 
time.    He  worked  night  au«d  clay  on  the  field  and  in  the  hos- 
pitals in  and  about  Sebastopol  in  the  eare  of  the  sick  and 
wounded.    It  was  AVork  of  a  n:tost  discouraging  kind.     All 
efforts  to  arrest  the  spread  of  the  death-dealing  diseases  proved 
futile.    The  most  careful  and  assiduous   treitment   only  too- 
often  proved  powerless  in  averting  death.    The  most  skilful 
operations  proved  useless  in  saving    limb   and  life,  for    the 
wounds,  as  a  rule,  became  infected,  and  a  very  large  per  cent, 
of  tho^ie  oi>erated  upon  died  from  sepsis,  pyemia,  erysipelas, 
hospital  gangrene  and  secondary  hemorrhage.   It  takes  courage 
to  follow  the  course  of  duty  under  such  trying  circumstances. 
Pirogoff  remained    at    his    post  as  long  as  his  services  were 
required,  and  performed  his  onerous  duties  with  an  enthusiasm 
and  faithfulness  that  commanded  the  respect  of  his  colleagues 
and  won  the  love  and  veneration  of  those  who  came  under  his. 
care.  When  physicians  hear  or  read  of  the  Siege  of  Sebastopol  the 
name  of  Pirogoff  invariably  suggests  itself  as  the  central  figure 
of  the  noncombatants  of  that  disastrous  contlict.    The  monu- 
ment   that    commemorates    his    deeds    in  the    most    worthy 
and  useful  manner  and  that  will  immortalize  his  fame  is  the 
Pirogoff  Museum.    The  Russians  have  honored  the  memory  of 
their  most  famous  surgeon  in  a  manner  that  merits  imitation. 
Can  we  say  the  same  of  our  countrymen  ?    What  have  we  done 
for  Benjamin  Rush,  one  of  the  signers  of  the  Declaration  of 
Independence,  the  eminent  physician,  the  erudite  author,  the 
great  teacher  and  the  first  Surgeon-General  of  the  United  States 
Army?    For  years  the  American  Medical  Association  has  tried 
in  vain  to  collect  enough  money  to  erect  a  suitable  monument 
to  the  memory  of  the  patriot  physician  in  the  Capitol  city. 
Why  not  found  and  maintain  a  Benjamin   Rush  Museum  in 
Chicago,  or  some  other  large  central  city,  on  the  same  plan  as 
the  Pirogoff  Museum,  as  a  permanent  home  for  the  American 
Medical  Association  and  its  official  organ?    Let  the  medical 
profession  of  the  United  States  answer  this  timely  question  by 
word  and  deed. 

Balaklava,  Russia,  June  7. 


(Reprinted  from  American  Medicine,  Vol.  IV,  No.  10,  pages  383-384, 
September  6,  1902.1 


MEDICAL  INSTITUTIONS  OF  ST.  PETERSBURG. 

BY 

NICHOLAS  SENN,  M.D., 
of  Chicago. 

St.  Petersburg  is  an  important  medical  center.  Nearly 
1,000  medical  students  are  preparing  themselves  here  annually 
for  their  lifework.  Russian  women  can  now  obtain  their  medi- 
cal education  at  home.  A  medical  school  has  been  opened 
recently  for  the  exclusive  use  of  women.  Heretofore  most  of 
the  female  medical  students  had  to  travel  to  Switzerland  to 
reach  the  goal  of  their  professional  ambition.  Outside  of  this 
school  medical  teaching  is  limited  to  the  Imperial  Military 
Academy.  This  is  the  only  institution  in  which  clinics  are 
conducted.  The  Military  Academy  is  an  immense  establish- 
ment, covering  as  it  does  several  blocks  of  ground.  It  is  under 
military  control  and  every  teacher  is  a  commissioned  officer. 
The  great  solid  buildings  face  the  majestic  Neva,  and  from  the 
bridge  present  a  magnificent  appearance.  The  students  must 
study  for  five  years  before  they  are  admitted  to  the  final  exam- 
inations. The  medical  cadets,  from  100  to  130,  are  educated 
at  the  expense  of  the  government.  The  final  examination 
they  have  to  pass  is  very  rigid  and  requires  more  than  six 
months.  The  hospital  connected  with  the  Academy  has  2,000 
beds  and  furnishes  all  of  the  practical  branches  in  medicine, 
with  an  abundance  of  clinical  material.  There  is  no  need  here 
of  extramural  teaching.  The  facilities  for  dissection  and  lab- 
oratory work  are  ample  and  w^ell  calculated  to  familiarize  the 
student  with  the  fundamental  branches  of  medicine.  In  this 
great  military  institution  gynecology  and  obstetrics  are  taught 
in  a  most  thorough  manner  by  a  military  officer.  The  nose, 
throat  and  ear  department,  under  the  supervision  of 
the  attending  physician  of  the  Empress,  is  probably  the 
finest  institution  of  its  kind  in  the  world.  It  is  a  new 
building,  constructed  upon  most  modern  and  approved  ideas 
and  lavishly  equipped  with  all  the  means  for  clinical  research 
and  scientific  investigation.  The  surgical  amphitheater  is 
somewhat  unique.  It  is  arranged  on  the  amphitheater  plan, 
and  can  seat  about  200  students.  Inside  of  the  amphitheater  is 
a  small  glass  house,  on  the  sides  and  on  top  of  which  are  seats 


for  the  students.  These  are  reached  by  a  very  steep  and  narrow 
staircase  made  of  iron,  and  from  every  step  the  operation  can 
be  seen  to  advantage.  The  professor  first  appears  outside  of 
this  house  of  glass,  explains  to  the  students  the  nature  of  the 
case  and  the  technic  of  the  operation,  and  then  enters  the 
sacred  precincts  and  performs  the  operation  without  any  further 
remarks.  The  students  watch  his  work  through  the  glass  Avails 
and  ceiling  while  the  operator  performs  his  task  silently,  unin- 
fluenced by  the  presence  of  his  outside  audience.  This  is  a 
plan  that  might  recommend  itself  for  postgraduate  work,  but 
it  is. a  very  questionable  one  in  teaching  the  young  student  how 
to  operate.  For  a  student  to  grasp  the  essential  features  of  the 
technic  of  an  operation  it  becomes  necessary  for  the  teacher  to 
explain  to  him  the  why  and  wherefore  of  every  step  of  what 
he  is  doing.  One  of  the  important  elements  in  successful 
teaching  in  this  institution  consists  in  limiting  the  attend- 
ance. The  hospital  as  a  whole  lacks  the  austere  appearance  of 
such  an  institution.  The  halls  and  staircases  throughout  the 
building  are  ornamented  by  works  of  art.  The  products  of 
sculptor  and  artist  are  on  exhibition  everywhere.  This  orna- 
mentation does  much  to  divert  the  mind  of  the  patients  in  a 
useful  direction,  and  to  fascinate  the  attention  of  the  visitors. 
All  of  the  sick  of  the  local  military  force  are  treated  in  this 
hospital,  at  the  same  time  adequate  provisions  are  made  for 
the  civilian  sick  poor.  Some  of  the  buildings  are  several  hun- 
dred years  old,  palatial  in  architecture,  recently  renovated  and 
improved  to  meet  all  of  the  modern  requirements,  including 
electric  light  and  hot- water  heating.  The  immense  clinical 
material  is  supplied  by  the  outdoor  department  or  polyclinic. 

PROFESSOR   vox   WREDEN'S   SURGICAL   CLIXIC. 

Professor  von  Wreden  is  a  military  officer  of  high  rank. 
He  is  in  the  prime  of  life,  a  diligent  student  and  perfectly  con- 
versant with  the  surgical  literature  of  the  present  day.  He 
knows  no  rest  between  the  hours  of  nine  in  .he  morning  and 
six  in  the  evening.  He  speaks  German  and  English  fluently. 
He  is  popular  with  the  students  and  is  the  friend  of  the  poor. 
His  calmness  and  self-control  in  the  operating  room  charm  his 
audiences  and  impart  confidence  in  his  patients.  Surface  dis- 
infection is  made  by  thorough  scrubbing  with  warm  water  and 
potash  soap  followed  by  alcohol  and  sublimate  solution.  The 
administration  of  ether  is  limited  to  patients  the  subject  of 
cardiac  lesions,  in  all  other  cases  chloroform  by  the  drop 
method  is  employed.  Catgut  has  been  entirely  abandoned  and 
Its  place  has  been  taken  by  silk  and  silver  wire.  Orderlies  and 
female  nurses  take  care  of  the  sick.    The  latter  are  furnished 


I 
3 

by  the  Russian  Red  Cross  and  receive  a  fair  salary.  The  assist- 
ants are  military  surgeons  of  large  experience.  Professor  von 
Wreden  is  a  warm  advocate  of  local  anesthesia.  He  uses  a  1% 
solution  of  cocaiu.  The  average  amount  of  this  solution 
employed  is  60  minims.  In  more  than  800  cases  he  has  never 
observed  any  serious  toxic  effects  from  this  drug.  I  was  given 
an  opportunity  to  witness  three  operations  under  this  method 
of  local  anesthesia. 

Case  1.— Staphylorrhaphy  for  syphilitic  defect  of  the  soft 
palate;  operation  under  local  anesthesia.  The  patient  was  a 
middle-aged  woman  npon  whom  a  rhinoplasty  for  syphilitic 
defect  of  the  nose  had  been  performed  a  number  of  weeks  ago. 
The  distal  phalanx  of  the  left  little  finger  had  been  successfully 
implanted  and  the  cosmetic  result  of  the  operation  was  quite 
satisfactory.  A  central  triangular  defect  of  the  soft  palate  was 
to  be  operated  upon  under  cocain  anesthesia.  With  a  small 
hypodermic  syringe  60  minims  of  a  1%  solution  were  injected 
into  the  border  of  the  defect  and  in  the  lines  of  incision  near 
the  alveolar  arch.  The  pharyngeal  mucous  membrane  was  also 
anesthetized  in  the  same  manner.  The  patient  was  placed  upon 
a  table  in  a  sitting  position  and  the  operator  stood  in  front  of 
her.  No  mouth-gag  was  used.  Hemorrhage  was  arrested  by 
compression.  The  Langenbeck  method  was  employed.  Three 
silver  wire  sutures  were  introduced  with  an  ordinary  well- 
curved  Hagedorn  needle.  The  twisting  of  the  wire  was  done 
with  Sims'  instrument.  The  index  finger  was  used  instead  of 
tissue  forceps  in  using  the  needles.  The  whole  operation  was 
completed  in  less  than  half  an  hour  and  evidently  without 
causing  much  pain.  This  method  of  anesthetization  is  em- 
ployed in  all  operations  for  cleft  palate  in  preference  to  the  use 
of  chloroform  or  ether. 

Case  II. — Relapsing  carcinoma  of  the  roof  of  the  mouth ; 
excision  under  local  anesthesia.  The  patient  was  a  man  ad- 
vanced in  years.  On  March  5  of  this  year  the  left  upper 
maxilla  was  excised  for  malignant  disease.  Recently  the 
carcinoma  returned  along  the  border  of  the  defect  on  the  roof 
of  the  mouth.  The  growth  was  a  spongy  mass,  about  the  cir- 
cumference of  a  silver  dollar.  A  1%  solution  of  cocain  was 
used  in  the  same  manner  and  quantity  as  in  the  first  case. 
Patient  was  placed  in  a  sitting  position  upon  a  table.  The  soft 
tissues  at  a  safe  distance  from  the  margins  of  the  growth  were 
divided  down  to  the  bone  with  the  knife-point  of  a  Paquelin 
cautery  ;  with  a  chisel  and  hammer  the  excision  of  the  tumor 
in  one  piece  was  completed.  The  operation  was  finished  in  a 
few  minutes  and  without  any  particular  complaint  on  part  of 
the  patient. 

Case  III. — Central  tuberculous  osteomyelitis  involving  the 
proximal  phalanx  of  the  middle  fliiger,  evidonent  under  cocain 
anesthesia.  The  patient  was  a  pale  and  somewhat  emaciated 
university  student.  The  disease  was  of  long  standing,  and  had 
its  starting  point  near  the  upper  epiphyseal  line  of  the  proxi- 
mal phalanx  of  the  right  middle  finger  and  had  terminated  in 
abscess  formation.  A  fistula  led  into  the  interior  of  the  bone. 
A  number  of  injections  were  made  in  a  circle  around  the  fistu- 
lous opening,  some  of  them  only  into  the  skin,  others  into  the 
deep  tissues  down  to  the  bone.  An  incision  was  then  made 
within  the  limits  of  the  anesthetized  area  and  parallel  with  the 


bone.  With  a  sharp  spoon  the  tuberculous  focus  was  removed 
and  the  wound  tamponed  with  iodoform  gauze  and  a  small 
absorbent  dressing  of  sterile  wood  wool  applied.  The  manner 
in  which  the  patient  behaved  showed  that  the  operation  was 
not  a  very  painful  one. 

For  the  purpose  of  preventing  the  depressing  effects  of 
cocain  a  liberal  dose  of  port  wine  is  administered  immediately 
before  the  injections  are  made.  As  a  wound  dressing,  sterilized 
Avood  wool  made  of  the  fir  tree  is  largely  employed. 

RED   CROSS    HOSPITAL   ALEXANDER. 

The  Russian  Red  Cross  Society  is  the  wealthiest  and  most 
influential  in  the  world.  It  has  the  moral  and  financial  sup- 
port of  the  Empress  Dowager..  It  has  in  its  treasury  at  the 
present  time  over  $8,000,000.    Its  organization  is  perfect   and 


Red  Cross  Hospital  Alexander,  St.  Petersburg. 

reaches  the  deserving  poor  throughout  the  entire  vast  empire. 
The  best  hospitals  in  St.  Petersburg  and  other  large  cities  are 
supported  and  managed  by  the  Red  Cross.  The  Red  Cross 
hospitals  in  St.  Petersburg  are  the  St.  George,  St.  Eugenie, 
Alexander  and  Elizabeth,  all  of  them  stately  buildings  and 
wisely  conducted.  The  Alexander  Hospital  is  one  of  the  finest 
and  best  equipped  hospitals  I  have  ever  visited.  It  is  a  solid 
square  building,  two  and  three  stories  high.  The  interior  is 
elegant,  the  furnitiire  luxurious.  None  of  the  rooms  contain 
more  than  two  or  three  patients.  The  halls  are  ornamented 
with  flowers,  shrubs  and  works  of  art.  Red  Cross  female 
nurses  take  care  of  the  sick.  The  size  of  the  building  is  alto- 
gether out  of  proportion  Avith  the  number  of  patients  it  can 
accommodate,  which  is  only  50.  There  are  no  free  beds.  The 
charge  for  room,  board,  nursing  and  treatment  is  from  $5  to  $15 


per  week.    The  surgeon  in  charge  lives  in  the  institution  in  a 
suite  of  rooms  that  leave  nothing  to  be  desired. 

ASEPSIS   OF   PROFESSOR   PAWLOFF. 

Professor  Pawloff,  who  is  in  charge  of  the  Alexander  Hos- 
pital, is  a  firm  believer  in  strict  asepsis.  He  has  no  use  for 
antiseptics.  After  each  day's  work  his  operating  room,  which 
is  an  excellent  one,  is  disinfected  with  live  steam.  The  few  vis- 
itors who  are  permitted  to  witness  his  work  must  appear  in 
sterilized  gowns  and  their  heads  must  be  covered  with  a  sterile 
worsted  Red  Cross  cap.  Soap  and  saline  solutions  are  relied 
upon  in  hand  and  surface  disinfection.  Linen  thread  sterilized 
by  boiling  is  the  suturing  and  ligature  material.  In  approximat- 
ing the  skin  he  makes  use  of  metallic  clamps  in  place  of  sutures. 
These  clamps  are  very  quickly  applied  and  readily  removed. 
A  number  of  delegates  to  the  Seventh  Conference  of  the  Inter- 
national Red  Cross  were  present  at  one  of  his  operations. 

The  patient  was  a  man,  aged  70,  who  had  a  tumor  in  the 
right  iliac  fossa.  The  anesthesia  was  commenced  with  ethyl- 
bromid  and  continued  with  chloroform.  An  incision  along  the 
inner  border  of  the  crest  of  the  ilium  and  Poupart's  ligament 
exposed  a  soft  tumor,  which  was  attached  to  the  inner  surface 
of  the  ilium.  The  center  of  the  tumor  was  cystic  and  on  rup- 
turing it  quite  a  large  quantity  of  bloody  serum  escaped.  The 
diagnosis  of  sarcoma  was  notdiflicu]t  at  this  stage  of  the  opera- 
tion. In  all  probability  it  was  a  sarcoma  of  the  iliac  fascia 
which  had  secondarily  implicated  the  periosteum  and  ])one  as 
the  tumor  mass  lacked  all  indications  of  osteogenesis  and  the 
surface  of  the  bone  was  not  extensively  affected.  With  forceps 
and  scissors  the  tumor  was  removed  piecemeal  and  with  chisel 
and  hammer  the  affected  part  of  the  bone  was  excised.  During 
the  dissection  the  retroperitoneal  fat  was  freely  exposed.  The 
wound  was  closed  with  two  figure-of-eight  deep  sutures  and, 
clamps  for  the  skin,  leaving  enough  space  for  drainage. 

Professor  Pawloff  resigned  from  the  faculty  of  the  Imperial 
Military  Academy  12  years  ago  and  is  now  devoting  all  of  his 
time  and  energies  to  the  work  of  the  Alexander  Red  Cross  Hos- 
pital. 

Sebastopol,  Russia,  June  8, 


[Reprinted  from  American  Medicine,  Vol.  IV,  No.  11,  pages  427-430, 
September  13, 1902.1 


CONSTANTINOPLE  AS  A  MEDICAL  CENTER. 

BY 

NICHOLAS  SENN,  M.D., 
of  Chicago. 

Emperor  Constantin  showed  good  judgment  and  a  pro- 
found knowledge  of  statesmanship  and  military  strategy  when 
he  chose  for  the  site  of  a  second  empire  city  on  the  banks  of 
the  Bosphorus,  the  gateway  between  the  Mediterranean  and 
Black  seas,  the  narrow  waterline  which  defines  the  limits 
between  two  great  continents.  Constantinople  is  beautifully 
situated,  scattered,  like  Rome,  over  seven  hills,  reflected  upon 
the  restless  bosom  of  the  Bosphorus  and  in  view  of  the  bare, 
rugged  mountains  of  Asia.  It  has  few  rivals  in  military  and 
commercial  importance.  Nature  has  made  its  fortification 
easy,  and  it  holds  the  key  to  the  commerce  on  the  great  seas 
which  swarm  with  merchant  vessels  from  all  parts  of  the 
globe.  The  city  claims  at  present  a  population  of  1,000,000, 
to  which  must  be  added  the  several  hundred  thousand  inhabi- 
tants of  its  many  suburbs  and  Scutari  on  the  Asiatic  side  of  the 
Bosphorus.  The  city  has  been  growing  quite  rapidly,  and 
shows  many  signs  of  recent  improvements.  It  lacks,  however, 
electric  street  railways  and  lighting.  Telephones  are  unknown 
throughout  Turkey.  The  most  promising  indications  of  a 
growing  civilization  are  to  be  seen  in  its  many  medical  institu- 
tions. Constantinople  is  the  great  and  only  medical  center  in 
Turkey. 

MEDICAL,   EDUCATION. 

The  only  two  medical  schools  in  Turkey  are  in  Constanti- 
nople, one  for  civilian  the  other  for  military  students.  Both  of 
these  institutions  are  under  strict  government  control  and 
nearly  all  of  the  teachers  are  military  surgeons.  The  new 
medical  university  is  located  in  Scutari  near  the  great  Haidar 
Pacha  military  hospital.  It  is  supplied  with  all  the  modern 
equipments  for  the  scientific  teaching  of  medicine  and  its  allied 
branches.  The  school  for  the  civilian  students  has  500  matricu- 
lants, the  military  700.  The  students  are  required  to  study  six 
years  before  they  are  permitted  to  apply  for  the  final  examina- 
tions. Tuition  is  free  for  the  military  cadets.  After  graduation 
the  young  officers  are  required  to  serve  as  assistants  in  one  or 
more  of  the  many  military  hospitals  for  a  period  of  two  years 
before  they  can  enter  the  regular  service.    If  for  any  reason  he 


leaves  the  service  before  the  expiration  of  30  years,  he  must 
refund  the  government  for  the  outlay  incident  to  his  profes- 
sional education.  After  30  years  of  continuous  service  he  can 
be  retired  on  half  pension.  A  full  pension  is  only  granted  after 
50  years  of  service.  Ample  provision  is  made  for  the  civilian 
graduates  for  interneship  after  their  graduation,  under  the  title 
of  voluntary  assistants.  Foreign  graduates  are  permitted  to 
practice,  but  they  have  no  legal  rights  and  cannot  hold  govern- 
ment appointments. 

TURKISH  MEDICAL  LITERATURE. 

Most  of  the  medical  books  used  in  the  university  are  trans- 
lations from  French  and  German  textbooks.  The  books  by 
Turkish  authors  are  few.  Among  them  are  works  on  materia 
medica,  physiology,  anatomy  and  on  operative  surgery  by 
Djemil  Pacha.  A  number  of  Turkish  medical  journals  bring 
short  abstracts  of  foreign  medical  literature  so  that  the  practi- 
tioners are  kept  in  touch  with  the  advances  in  medicine  and 
surgery  outside  of  the  Ottoman  Empire.  The  government 
sends  annually  many  of  the  military  and  naval  medical  officers 
to  Paris  and  Germany  for  postgraduate  work,  a  movement 
which  has  been  the  principal  means  of  establishing  Turkish 
medical  education  and  medical  literature  on  a  scientific  basis. 
The  spirit  of  original  research  and  scientific  investigation  has 
taken  hold  of  the  rank  and  file  of  the  Turkish  profession,  and 
in  a  very  few  years  we  may  look  for  a  rich  Ottoman  medical 
literature. 

MEDICAL   SOCIETIES. 

Turkey  has  no  national  medical  society.  The  vast  expanse 
of  the  country,  the  limited  means  of  transportation,  render  it 
very  difficult  to  organize  the  whole  profession  into  one  body. 
Many  of  the  physicians  who  live  in  small  inland  cities  and  vil- 
lages are  isolated  and  remain  in  communication  with  the  out- 
side world  only  by  mail.  Such  segregation  leads  only  too  often 
to  routine  practice  and  clogs  the  wheels  of  progress.  Compara- 
tively few  civilian  physicians  avail  themselves  of  postgraduate 
work  beyond  the  limits  of  their  own  country.  It  is  for  this 
class  of  physicians  that  medical  societies,  large  and  small, 
become  the  most  useful  postgraduate  institutions.  A  national 
medical  society  would  be  of  the  greatest  utility  in  stimulating 
the  mass  of  the  profession  in  this  country  to  united  action  and 
could  not  fail  in  advancing  the  cause  of  medicine  and  surgery. 
Constantinople,  the  great  medical  center  of  Turkey,  has  recently 
made  a  good  beginning  in  organizing  the  profession.  It  has  a 
medical  society  with  Djemil  Pacha  as  president.  The  society 
holds  weekly  meetings  which  are  well  attended  and  at  which 
the  scientific  aspects  of  medicine  and  surgery  receive  merited 


attention.  The  euoi'nious  clinical  material  offered  by  the 
numerous  hospitals  of  this  great  city  should  and  will  be  made 
available  for  the  outside  world  through  the  excellent  scientific 
work  of  our  enthusiastic  and  energetic  Turkish  colleagues. 

HOSPITALS. 

Constantinople  is  well  supplied  with  hospitals.  The  gov- 
ernment takes  excellent  care  of  its  soldiers  when  disabled  by 
injury  or  disease  and  its  indigent  sick.  The  city  has  no  less 
than  30  military  hospitals.  The  largest  one,  the  Haidar  Pacha, 
with  1,500  beds,  is  located  beautifully  on  a  high  elevation  on  the 
Asiatic  side  of  the  Bosphorus.  It  was  in  this  hospital  that 
Florence  Nightingale  gained  her  undying  reputation  during 
the  Crimean  war.  It  was  my  privilege  during  the  Greco- 
Turkish  war  to  visit  these  hospitals  when  the  wards  contained 
hundreds  of  wounded  soldiers.  I  shall  ever  remember  with 
gratitude  the  many  courtesies  that  were  extended  to  me  at  that 
time  by  the  government  and  the  medical  officers.  To  visit  any 
of  these  hospitals  it  is  necessary  to  secure  a  permit.  This  is 
received  on  application  through  the  Minister  of  the  United 
States,  in  the  case  of  Americans,  when  the  application  is  trans- 
mitted through  military  channels.  On  my  second  visit  Mous- 
tafa  Bey,  a  lieutenant-major  at  the  Yildiz  Palace,  was  detailed 
as  chaperon.  How  well  the  preparations  were  made  for  the 
visit  became  evident  when  Ave  called  at  the  different  hospitals 
and  always  found  the  chief  surgeon  and  his  staff  in  full  dress 
uniform  awaiting  us  at  the  entrance-  The  whole  staff  accom- 
panied us  on  our  tour  through  the  different  parts  of  the  build- 
ings. Coffee  and  cigarets  were  invariably  served  in  the  office  of 
the  chief  surgeon  at  the  completion  of  the  visit.  I  will  only 
refer  to  three  of  the  larger  hospitals  visited. 

Yildiz  {Star)  Hospital.— This  hospital,  near  the  Yildi/ 
Palace,  was  built  during  the  Greco-Turkish  war  for  the 
wounded.  In  less  than  four  weeks  barracks  for  1,000  patients 
were  in  readiness.  The  buildings  remain  much  the  same  as 
during  the  war.  The  wounded  have  all  disappeared,  some  of 
the  barracks  are  empty  and  only  about  200  patients  are  cared  for 
at  the  present  time.  Brigadier- General  Rachid  Pacha  directs 
the  affairs  of  this  hospital,  assisted  by  a  staff  of  surgeons.  The 
main  feature  of  this  hospital  at  the  present  time  is  a  large  bath- 
house for  Turkish  baths.  It  is  noteworthy  to  make  the  state- 
ment, ascertained  by  a  number  of  inquiries  at  the  different  hos- 
pitals, that  venereal  diseases  are  quite  uncommon  among  the 
soldiers  of  the  Ottoman  Army.  The  principal  affections  which 
figure  most  conspicuously  on  the  hospital  register  are  bron- 
chitis, pneumonia,  typhoid  fever,  rheumatism,  sprains  and 
fractures.    Alcoholism  is  unknown.    The  operating  room  is 


small,  well  lighted  and  supplied  with  the  most  necessary  con- 
veniences for  aseptic  work.  In  case  of  another  war  it  is  to  this 
hospital  the  wounded  would  find  their  way  first,  as  its  location 
outside  the  noisy  limits  of  the  city  and  the  general  arrange- 
ments of  the  buildings  would  recommend  it  for  such  special  use 
in  preference  to  the  other  military  hospitals. 

Guniuche-Souyou  Hospital.— Thin  hospital  is  located  on  the 
north  side  of  the  city,  and  furnishes  accommodations  for  400 
patients.  The  building,  a  solid  two-story  structure,  is  more 
than  100  years  old,  and  did  excellent  service  during  the  Crimean 
war.  It  is  in  charge  of  Colonel  Selami  Bey,  a  veteran  military 
surgeon.  The  halls  and  wards  are  at  least  20  feet  in  height  and 
well  lighted.  This  feature  of  the  building,  with  the  wide  stone 
stairs  and  columns  of  stone  in  the  front,  impart  to  it  a  palatial 
appearance.  The  iron  bedsteads,  clean  pillows,  soft  woolen 
Ijlankets  and  comfortable  mattresses  rob  the  old  building  of 
its  former  austerity.  The  medical  work  in  all  of  the  military 
hospitals  is  classified  into  surgical  and  medical.  Ophthalmology 
is  the  only  specialty  that  is  recognized.  In  this  hospital  Dr.  A. 
Hazim  is  the  operator,  and  Dr.  H.  Sarim  the  oculist.  The  con- 
valescents find  a  pleasant  place  for  recuperation  in  the  tree-clad 
garden,  beautified  with  flowers,  in  the  front  yard  of  the  hos- 
pital. A  fountain  in  this  garden  is  now  in  process  of  construc- 
tion. The  nursing  in  all  the  military  hospitals,  as  well  as  all 
housework,  is  done  exclusively  by  men.  The  soldiers  receive 
well-cooked,  plain,  substantial  food  and  wear  comfortable 
hospital  clothes  from  the  time  they  enter  until  they  are  dis- 
charged. During  the  last  year  5,842  patients  were  treated  in 
this  hospital,  with  only  72  deaths,  certainly  a  most  gratifying 
record. 

The  Hamidie  Hospital. — This  is  the  finest  and  most  complete 
hospital  in  Turkey,  and  has  few,  if  any  equals  of  its  kind  in  the 
world.  This  hospital,  the  just  pride  of  the  Sultan  and  the  local 
profession,  is  a  memorial  to  one  of  his  favorite  little  daughters, 
who  died  several  years  ago.  It  was  built  and  is  maintained  at 
the  private  expense  of  the  Sultan.  The  outside  world  knows 
little  of  the  work  of  civilization  and  deeds  of  charity  of  His 
Imperial  Majesty,  Abdul  Hamid  II.  He  has  always  manifested 
a  deep  interest  in  the  advancement  of  the  science  of  mediciue 
and  works  of  charity.  A  prominent  Turkish  physician  says  of 
him : 

His  Majesty,  the  Sultan,  is  the  greatest  and  most  energetic 
advocate  of  medical  science  in  his  great  empire. 

Before  he  ascended  the  throne  there  were  few  physicians  in 
Turkey,  and  science  was  not  as  far  advanced  as  at  the  present 
time.  During  the  reign  of  our  exalted  and  kind  ruler,  medi- 
cine has  so  far  advanced  that  we  have  a  number  of  distinguished 
surgeons    like     Djemil     Pacha,     Haireddin     Pacha,     Osman 


Pacha,  Fikry  Bey,  Noureddiii  Bey,  Nazim  Bey,  Hazim  Bey, 
Kudrftt  Bey,  Halid  Bey  and  Omer  Bey.  The  same  can  be 
said  of  internal  medicine.  In  this  field  we  also  have  in  Turkey 
distinguished  professors,  who  received  their  education  in 
France  or  Germany  and  who  upon  their  return  entered  our 
medical  school  as  teachers. 

That  the  Sultan  has  been  a  much  misrepresented  man  no 
one  who  has  traveled  through  Turkey  can  deny.  Here  is  an 
institution  that  serves  as  a  living  witness  against  the  unfounded 
charge  of  heartlessness  and  cruelty.  An  institution  in  which 
the  very  air  breathes  a  spirit  of  kindness,  charity  and  a  deep 
concern  for  the  proper  care  of  the  sick  poor  that  will  for  all 
times  commemorate  the  greatest  virtues  of  the  present  ruler  of 
Turkey.    Let  the  monarchs    of  more  civilized  nations  cover 


1^ 


-;0 


p^^ 


i^a       ■«     « 


Hamicli6  Hospital.     Main  building  and  pavilion. 

their  faces  with  shame  when  they  visit  the  Hamidie  Hospital 
in  Constantinople.  Every  man  has  his  faults,  and  no  ruler  of 
nations  is  perfect,  but  here  is  an  institution  that  will  always 
testify  to  the  kindness  of  heart  and  liberality  to  the  poor  of 
Abdul  Hamid  II.  The  annual  expenses  of  the  hospital  amount 
to  about  §75,000,  and  they  are  all  paid  out  of  the  private  purse  of 
the  Sultan.  The  scope  of  the  hospital  is  limited  to  the  treat- 
ment of  women  and  children.  It  is  located  in  Schischli,  in 
Pera,  at  the  northern  terminus  of  the  city,  on  a  high  hill,  from 
which  the  city,  the  Bosphorus,  Scutari,  and  in  the  distance  the 
Sea  of  Marmora  and  the  mountains  on  the  Asiatic  side  can  be 
seen.    No  more  healthful  and  pleasant  location  could  have  been 


(> 


selected.  A  large  tract  of  land  around  it  is  being  planted 
with  trees  and  shrubs,  and  is  laid  out  in  parklike  fashion. 
Flower  gardens  and  a  fountain  add  much  to  the  beauty 
and  charms  of  the  place.  The  main  building  contains 
rooms  for  the  director  and  his  assistants,  the  pharmacy,  and  14 
rooms  for  the  employes,  chapel  and  library.  The  dwelling 
rooms  are  furnished  in  a  most  luxurious  oriental  style.  The 
hospital  proper  is  built  on  the  pavilion  plan  and  can  accommo- 
date 100  patients.  The  wards  are  models  of  cleanliness  and 
comfort.  The  operating-room  is  all  that  money  and  skill  could 
make  it.  It  is  supplied  with  all  conveniences  for  aseptic  work 
and  a  complete  outfit  of  surgical  instruments.  The  washhouse, 
sterilization-room  and  steam-heating  apparatus  occupy  a  sepa- 


Medical  staff  of  the  Hamidie  Hospital. 


rate  building.  A  military  guardhouse  is  at  the  entrance  to  the 
grounds  and  a  small  detachment  of  soldiers  do  guard  duty.  In 
the  well  equipped  pathologic  and  bacteriologic  laboratory  the 
best  scientific  work  is  being  done.  This  department  is  in 
charge  of  Fnad  Bey,  who  qualified  himself  for  this  position 
under  Finkler,  Kruse,  Schulze,  Behring,  Marmkopf,  Muller 
and  Striimpell,  all  wellknown  German  scientists.  Djevad  Bey, 
also  a  graduate  of  a  foreign  school,  is  the  chemist  of  the  insti- 
tution and  does  his  work  in  a  separate  laboratory  furnished 
with  everything  necessary  for  scientific  work.  Most  of  the 
furniture  and  hospital  supplies  were  bought  in  Paris  and  Ger- 
many regardless  of  cost.  The  director's  house  is  furnished  in 
princely  style.    The  present  medical  staff  consists  of  Colonel 


Ibrahim  Bey,  medical  director  and  physician  to  H.  I.  M.  the 
Sultan;  Fuad  Bey,  Yakki  Bey,  Nonri  Bey,  Zia-Noumry  Bey. 

The  greatest  defect  in  all  of  the  Turkish  hospitals  is  the 
absence  of  trained  female  nurses.  The  high  class  Turkish 
women  are  not  obtainable  and  the  low  class  women  do  not  pos- 
sess the  necessary  education  and  intelligence  to  fit  themselves 
for  the  nursing  profession.  The  Hamidie  Hospital  has  found  a 
Avay  out  of  this  difficulty.  Seven  months  ago  five  trained 
female  nurses  were  engaged  in  Berlin  and  after  coming  here 
were  placed  in  charge  of  the  sick  children  and  women.  This 
addition  to  the  hospital  has  wrought  wonders  in  the  care  of  the 
patients.  Their  services  are  highly  appreciated.  The  head 
nurse  receives  70  francs  a  month,  the  rest  from  40  to  50.  These 
five  young  women  are  happy  and  cheerful  in  their  present 
situation,  although  they  have  as  yet  made  but  little  progress  in 
acquiring  a  knowledge  of  the  Turkish  language.  It  is  to  be 
hoped  that  their  work  and  example  will  set  aside  the  objections 
of  the  highborn  Turkish  women  to  join  their  work  and  open 
the  way  to  well  trained  native  female  nurses.  If  it  were  not  for 
the  red  fez  a  visit  to  this  hospital  would  leave  the  impression 
that  the  visitor  had  passed  through  one  of  the  most  modern  and 
scientific  hospitals  in  Germany.  This  hospital  will  furnish  the 
leaven  in  the  further  evolution  of  the  science  of  medicine  in 
Turkey  and  will  become  an  object  lesson  in  the  care  of 
the  sick  throughout  the  entire  empire.  No  private  hospital 
offers  more  comfort,  better  nursing  or  more  attentive  and 
careful  medicaland  surgical  treatment,  and  yet  it  is  a  rule 
established  by  the  royal  donor  that  no  money  should  be 
taken  from  any  of  the  patients.  Children  from  1  to  12  years 
of  age  embrace  the  largest  number  of  patients.  The  gyne- 
cologic department  is  well  represented.  Several  pavilions  are 
devoted  to  acute  infectious  diseases.  Serum  treatment  of  diph- 
theria is  relied  upon,  and  has  given  the  most  gratifying  results. 
Last  year  two  children  with  far-advanced  diphtheritiG  stenosis 
of  the  larynx  were  admitted.  In  both  instances  tracheotomy 
was  immediately  performed,  and  both  recovered.  Tuberculosis 
of  bones,  joints  and  lymphatic  glands  is  quite  a  frequent  affec- 
tion among  the  children.  Diseases  of  the  skin  and  eyes  make 
up  a  large  part  of  the  clinical  material.  One  of  the  provisions 
tliis  hospital  has  in  view  is  the  care  of  strangers  that  might  be 
taken  ill  in  Constantinople.  At  the  Sultan's  special  request  16 
beds  have  been  set  aside  for  the  treatment  of  patients  that 
might  apply  for  relief  to  any  of  the  legations.  All  that  is  neces- 
sary to  secure  admittance  is  to  apply  to  any  one  of  the  ambas- 
sadors for  a  recommendation.  I  do  not  know  of  any  other 
monarchical  or  republican  government  that  has  made  a  similar 
arrangement  for  tlie  travelers  of  other  countries  in  case    of 


illness— another  indication  of  the  Sultan's  desire  to  benefit  the 
sick,  regardless  of  their  nationality  or  religious  belief.  The 
question  of  religion  is  never  raised  in  admitting  patients.  In 
looking  over  the  report  for  last  year,  I  found  that  at  least  33%  of 
all  the  patients  were  Protestants. 

Polyclinic  of  the  Hamidie  Hospital.— One  of  the  most  far 
reaching  charitable  institutions  of  Constantinople  is  the  Poly- 
clinic connected  with  the  Hamidie  Hospital.  The  average  daily 
attendance  is  from  125  to  150.  Last  year  25,000  applied  for  treat- 
ment. All  patients  must  pass  through  the  same  gate.  Inside 
of  the  gate  is  the  first  examination  station.  A  physician  elimi- 
nates here  all  cases  of  acute  infectious  diseases  which  are 
referred  at  once  to  the  department  for  the  same.  Those  who  are 
admitted  enter  the  large  waiting-room.      Another  physician 


Polyclinic  of  Hamidie  Hospital. 


classifies  the  patients  and  refers  them  to  the  department  to 
which  they  belong.  Five  physicians,  representing  surgery, 
internal  medicine,  gynecology,  ophthalmology  and  nose  and 
throat  diseases  in  separate  rooms  are  in  attendance  from  9  a.m. 
until  2  p.m.  All  of  these  rooms  are  well  supplied  with  instru- 
ments for  diagnosis  and  treatment.  A  large  dispensary  in  the 
same  building,  presided  over  by  several  competent  druggist*, 
supply  the  medicines  free  of  charge.  Ibrahim  Bey  is  the  soul 
of  the  Hamidie  Hospital.  He  takes  great  pride  in  its  marvel- 
ous success.  He  is  a  competent  bacteriologist,  a  thorough  and 
earnest  student  of  the  German  medical  literature  and  passion- 
ately devoted  to  the  advancement  of  the  science  of  medicine  in 
its  broadest  sense.    Our  visit  in  this  model  hospital  terminated 


with  a  most  excellent  dinner  given  at  the  special  request  of  the 
royal  founder  and  patron,  H.  I.  M.  the  Sultan. 

THE   TURK   AS   A   SOLDIER. 

The  Turk  makes  an  ideal  soldier.  He  is  above  average 
height  with  a  splendid  physique,  muscular  and  devoid  of  super- 
fluous fat.  His  simple,  temperate  habits  engender  an  endurance 
far  beyond  that  of  the  soldiers  of  any  other  European  nation. 
The  Turk  can  subsist  on  a  minimum  of  the  plainest  kind  of 
food  without  becoming  disabled  on  forced  marches  continued 
for  many  days.  The  Turkish  soldier  is  content  and  obedient. 
His  sense  of  duty  is  keen  and  he  will  follow  his  leader  in  the 
very  jaws  of  death  without  fear.  The  Turkish  army  has  become 
a  very  formidable  one.  It  is  well-drilled  and  organized  and 
armed  with  modern  weapons.  All  able-bodied  Turks  enter  the 
army  at  the  age  of  20  and  serve  for  seven  years.  In  Constan- 
tinople alone  there  are  17,000  soldiers  who  live  in  modern  com- 
fortable barracks.  The  Turkish  cavalry  is  the  finest  in  the 
world.  The  Turkish  soldier  is  a  desirable  patient.  He  has 
faith  in  his  physician  and  is  grateful  for  his  services.  Obedi- 
ence, courage  and  patience  are  his  greatest  virtues. 

THE    RED   CRESCENT. 

In  the  Turkish  army  the  Red  Crescent  is  equivalent  to  the 
Red  Cross.  The  red  crescent  on  the  sleeve  and  on  the  white 
flag  means  the  same  practically  as  the  red  cross.  The  Red 
Crescent  Society  of  Turkey  is  a  very  exclusive  organization. 
It  is  made  up  almost  entirely  of  military  men  who  have  dis- 
tinguished themselves  by  meritorious  service.  Membership 
in  this  society,  in  fact,  means  government  recognition.  At  the 
last  Conference  of  the  International  Red  Cross  this  society  was 
represented  by  the  Turkish  Ambassador  at  St.  Petersburg,  who 
attended  all  of  the  sessions  and  manifested  a  deep  interest  in  its 
proceedings. 

Constantinople,  June  13. 


fUeprinted  from  American  Medicine,  Vol.  IV,  No.  12,  pages  467-469, 
iSeptember  20,  1902  1 


MEDICAL  AND  SURGICAL  NOTES  FROM  ASIA. 

BY 

NICHOLAS  SENN,  M.D., 
of  Chicago. 
It  is  a  long  time  since  the  great  continent  of  Asia  was  the 
center  of  civilization,  art,  science  and  Cliristianity.  For  nearly 
2,000  years  progress  has  given  place  to  decay.  Her  treasures  of 
art  lie  buried  under  her  arid  soil  or  have  found  their  way  into 
the  rich  museums  of  distant  nations.  Her  science  has  been 
transplanted  to  a  more  fertile  soil  in  foreign  lands.  The  light 
of  Christianity  kindled  in  Asia  has  become  almost  extinguished 
by  the  worshipers  of  strange  gods,  and  is  now  illuminating 
inore  brightly  Europe,  Africa  and  the  two  continents  that  were 
unknown  when  it  was  given  to  God's  chosen  people.  The  dark 
clouds  created  by  the  relentless  persecution  of  the  Christian 
church,  the  ^reat  power  of  civilization,  still  hover  over  the 
unfortunate  contihent  and  are  being  only  gradually  dispersed 
by  the  reintroduction  of  the  teachings  of  Him  who  selected  this 
land  for  his  soul'-savihg  mission  on  earth.  In  a  land  where 
there  is  no  art  and' no  science  medicine  cannot  flourish.  Super- 
stition'and  medicine  are  incompatible  neighbors.  Science 
should  precede — it  certainly  must  accompany— progressive 
inodern  medicine^  If  Hippocrates  could  return  to  his  birth- 
place in  the  island  of  Kos,  near  the  coast  of  Asia,  he  would  find 
kmple  indications  that  the  science  of  medicine  which  he 
founded  400  years  before  the  Christian  era  had  found  a  new 
l"oothold  in  many  parts  of  dark  Asia.  What  progress  has  been 
made  in  Asia  in  the  teaching  sind  practice  of  medicine  during 

(he  last  half  century  has  been  accomplished  entirely  by  outside 
nfluences. '  The  medical  missionaries  and  foreign  physicians 
^re  establishing  in  many  different  places  institution^  where 
inodern  scientific  medicine  is  taught  and  prdctis^d  and  frorn 
ivhere  the  good  work  will  gradually  but  surely  extend  over  thi^ 
^utire  continent.  It  is  my  purpose  to  speak  of  A  few  such  med- 
ical centers  in  this  dommunidation.  '  '        "  ' 

SMYRNA. 

Smyrna  is  one  of  the  great  commercial  ports  of  Asiatic 
Turkey.  It  has  a  nlix6d  population  of  125,000  inhabitants. 
"The  Greek's  ai^e^well  represented  knd  control  mtich  df  its  cofn- 
ii:ierci'af  irfter'^sts.  Th^'y  oWn  and  rhaintain  a  large  hospital  for 
the   sick  of  their  o^frn  nktion'ality.    They  gained  a  firm  foothold 


on  this  part  of  the  Asiatic  soil  centuries  ago,  and  have  been 
more  successful  in  business  matters  than  most  of  the  other 
exotics.    The  richest  men  in  Smyrna  are  of  Greek  origin. 

The  Yosharalamhas  Hospital. — This  institution  for  the 
Greek  sick  poor  in  Smyrna  is  a  credit  to  the  little  nation  it  rep- 
resents. It  is  more  than  150  years  old  and  is  located  in  the 
very  heart  of  the  city.  It  is  a  solid  square  building  two  stories 
high  with  a  central  open  court  where  the  patients  enjoy  the 
luxuries  of  a  subtropical  garden  and  pleasant  walks.  The 
wards  are  large,  well  ventilated  and  supplied  with  all  the  com- 
forts of  a  modern  hospital.  The  medical  staff  is  composed  of 
young  men,  graduates  of  the  University  of  Athens,  and  most 
of  them  have  taken  postgraduate  courses  in  Paris.  Smyrna 
surgery  is  French  surgery.  One  operating-room  is  devoted 
entirely  to  aseptic  surgery,  in  the  other  all  the  facilities  for 
antiseptic  work  are  at  the  disposal  of  the  operator.  In  the 
aseptic  room  the  appliances  for  sterilization  of  instruments, 
dressings,  suturing  and  ligature  material  are  complete.  Like 
in  all  Oriental  hospitals  the  absence  of  trained  female  nurses  is 
a  deplorable  feature.  Dr.  A.  N.  Psaltoflf  is  the  most  distin- 
guished member  of  the  medical  staff  of  this  hospital.  He  spent 
several  years  after  his  graduation  in  Paris,  and  is  familiar  with 
French  medical  literature.  He  is  an  able  and  successful  sur- 
geon, and  his  example  and  teachings  will  contribute  much 
toward  disseminating  modern  surgery  in  Asia.  Other  foreign 
nations  in  Smyrna  own  and  support  their  own  hospitals,  among 
them  the  French  and  Austrian  governments. 


Beyrut  is  the  Paris  of  Syria.  It  is  a  city  of  75,000  inhabi- 
tants, located  on  an  eminence  which  commands  a  splendid  view 
of  the  Mediterranean  Sea  on  one  side  and  the  Lebanon  Moun- 
tains on  the  other.  Here  a  new  civilization  and  modern  medi- 
cine have  engrafted  themselves  more  firmly  than  in  any  other 
part  of  Asia,  all  through  the  strong  influence  of  the  Syrian 
Protestant  College. 

fSyrian  Protestant  College.— This  is  an  American  mission- 
ary institution  founded  36  years  ago  by  the  retiring  president, 
Rev.  Daniel  Bliss,  D.D.  It  is  known  by  the  citizens  of  Beyrut 
as  the  American  College.  The  massive  stone  buildings  are 
distributed  over  a  36-acre  lot  located  on  the  shore  of  the  Medi- 
terranean on  one  side  and  shut  out  from  the  city  by  a  high 
stone  wall  on  the  other.  New  buildings  are  erected  as  they  are 
needed.  At  present  the  great  Post  Hall  is  in  process  of  con- 
struction and  when  completed  will  be  used  as  a  science  hall. 
The  Daniel  Bliss  Hall  is  a  magnificent  college  building.  The 
college  has  an  attendance  of  600  young  men  who  have  come 


3 


here  to  obtain  their  education  from  various  countries,  includ- 
ing Syria,  Turkey  in  Europe,  Greece,  Palestine  and  Egypt. 
Tlie  teaching  force  is  composed  of  40  professors  and  instructors 
The  faculty  includes  a  number  of  names  of  former  graduates. 
The  college  has  six  departments:  preparatory,  collegiate, 
school  of  commerce,  school  of  biblical  archaeology  and  phi- 
lology, medicine,  and  pharmacy.  New  departments  will  be 
added  as  fast  as  the  finances  of  this  excellent  institution  will 
permit.  What  is  much  needed  is  a  department  of  dentistry 
and  agriculture. 

/School  of  Medicine. — This  was  organized  by  Prof.  George 
E.  Post  in  1867.  It  has  a  list  of  91  graduates  up  to  the  present 
time.  It  has  more  than  100  matriculants  and  the  graduating 
cjasis  for  this  year  numbers  10.   The  faculty  is  oompos^ed  of  eight 


Medical  Hall. 

members.  Some  of  these  teachers  fill  several  chairs.  For 
instance.  Prof.  Adams  teaches  chemistry,  materia  medica, 
therapeutics  and  dermatology,  and  Prof.  Moore  gynecology, 
obstetrics,  physiology  and  hygiene.  Recitations  constitute  a 
conspicuous  feature  of  all  didactic  courses.  One  of  the  difficul- 
ties encountered  by  the  college  of  medicine  is  the  supply  of 
material  for  the  dissecting-room.  The  cemeteries  are  the  only 
places  where  the  material  can  be  obtained  and  the  midnight 
excursions  for  this  particular  purpose  are  attended  by  great 
difficulties.  The  bodies  are  carefully  preserved  in  alcohol  so 
as  to  utilize  them  to  the  utmost  advantage.  The  college  build- 
ing compares  favorably  with  some  of  our  smaller  medical 
schools.  Two  amphitheaters  serve  as  lecture-rooms.  A 
museum  furnishes  ample  facilities  for  the  study  of  compara- 
tive anatomy,  pathology  and  osteology.   The  present  laboratory 


4 


advantages  are  not  what  they  should  be,  but  a  large  building 
now  in  process  of  construction  will  remedy  this  defect  at  the 
beginning  of  the  next  session.  The  tuition  is  ^0  annually  and 
half  of  this  fee  secures  admission  for  graduates  of  the  Syrian 
Protestant  Hospital,  Robert  College,  Central  Turkey  College, 
Anatolia  College,  and  of  Euphrates  College.  The  requirements 
for  admission  specify  the  minimum  age  at  17,  and  a  satisfactory 
examination  in  English,  French  or  Turkish,  geography,  arith- 
metic, elementary  physiology,  algebra,  geometry  and  physics. 
After  four  years'  study  and  after  having  passed  a  satisfactory 
written  and  oral  examination,  the  students  receive  a  certificate 
of  examination'.  This  certificate  entitles  them  to  apply  for 
"graduation  to  the  imperial  Medical  School  at  Constantinople. 
In  Egypt  this  certiAcate  entitles  the  holder  to  enter  into  prac- 
tice without  any  further  examination.  A  number  of  the  gradu- 
ates are  now  serving  as  military  surgeons  in  the  Egyptian  army 
knd  others  hold  important  municipal  medical  positions. 

The  Johanniter  Hospital. — This  hospital  was  founded  in 
1867  by  the  German  branch  of  the  Knights  of  St.  John,  and 
receives  the  warm  support  and  financial  aid  of  this  order.  It  is 
a  two-story  stone  building,  situated  on  a  high  bliiff  which  over- 
looks the  Mediterranean  Sea.  It  contains  70  beds,  and  is  in 
charge  of  eight  deaconesses  from  Kaisersworth.  These  eight 
well-trained  Sisters  take  excellent  care  of  the  patients  and  are  of 
great  assistance  to  the  attending  staff.  All  of  the  clinical  teach- 
ing of  the  medical  school  takes  place  in  this  hospital.  Professor 
tost  holds  his  clinics  Wednesday  and  Saturday  forenoons  each 
week.  The  students  attend  in  sections  of  from  12  to  20.  As 
there  are  no  house  physicians  in  the  hospital  the  students  assist 
in  operations  ancl  attend  to  most  of  the  dressings.  The  operat- 
ing-room is  snaall  but  contains  everythiugnecessary  for  aseptic 
work.  All  of  the  students  wear  go^vtis.  Those  who  are  called 
\ipon  to  assist  must  undergo  a  most  thorough  hand  disinfection. 
^ost  is  pattial  to  silk  as  a  suturing  material,  altliough  occasion- 
ally he  makes  Use  of  catgut  or  silver  wire. 

On  the  day  of  my  visit  he  operated  for  congenital  inguinal 
hernia  occurring  in  a  man  about  35  years  old.  The  opposite 
side  had  been  operated  upon  successfully  six  weeks  ago.  The 
operation  was  performed  under  cocain  anesthesia. 

Post  prefers  local  to  general  anesthesia  in  such  cases.  His 
experience  with  this  local  anesthetic  has  been  quite  extensive, 
and  although  he  has  administered  in  some  cases  as  much  as  \l 
grains  of  the  drug  in  this  manner  he  has  never  observed  any 
serious  after  effects. 

In  this  particular  case  the  patient  frequently  manifested 
bain  on  incising  the  skin  and  in  making  the  deep  dissection^ 
The  oihentiim  ptersisted  in  protruding  on  opening  the  S£lc  and  i 


large  part  of  it  was  finally  amputated  below  a  number  of  &ti 
■masse  silk  ligatures.  This  part  of  the  operation  appeared  to  be 
painless.  The  hernial  opening  was  very  large  and  conse- 
quently had  to  be  closed  by  suturing  instead  of  by  a  ligature. 
The  spermatic  cord  was  not  disturbed  and  the  inguinal  canal 
was  closed  with  a  number  of  silk  ligatures. 

The  operation  was  a  somewhat  tedious  one  and  the  two 
other  operations  set  for  the  same  day,  a  cystic  bronchocele  and 
a  relapsing  sarcoma  of  the  face,  had  to  be  postponed  for  the 
next  clinic. 

Among  the  interesting  cases  exhibited  were :  Ovariotomy 
for  dermoid  cyst,  enterectomy  for  fecal  fistula  following  opera- 
tion for  strangulated  hernia,  thyroidectomy  for  parenchyma- 
tous struma  of  ri^ht  lobe  of  thyroid,  excision  of  carcinoma  of 
l^reast  and  a  numl;)er  of  cases  of  tuberculosis  of  joints,  all  of 
them  progressing  favorably. 

Professor  George  E.  Post  is  a  most  remarkable  man.  iteis 
the  most  popular  physician  in  Syria,  respected  and  honored  by 


;r^ 

1 

1 

K^'-i 

r.f^v.<"^j^^|?g^ 

k;  S^"*f" 

The  Johanniter  Hospital. 

_all  classes  of  people  for  what  he  has  done  for  the  country.  His 
students  fairly  worship  him.  He  is  the  son  of  the  distinguished 
Jate  Professor  Alfred  C.  Post,  of  New  York.  He  came  to 
Beyrut  soon  after  his  graduation  in  1863  and  has  worked  inces- 
santly ever  since.  He  loves  the  people  and  the  country  of  his 
adoption  and  his  work  will  be  revered  and  honored  by  genera- 
tions to  come.  The  secret  of  his  almost  unparalleled  success  has 
been  work.  He  has  accomplished  what  he  has  by  systematizing 
)iis  work,  and  his  hours  of  rest  are  few,  but  are  taken  at  a  regu- 
lar time.  He  has  given  to  the  college  he  loves  nearly  one-half 
of  his  time.  Vacation  he  knows  not,  work  is  his  recreation. 
Resides  a  large  and  taxing  surgical  practice  he  has  found  time 
to  prepare  an  Arabic  Commentary  of  the  Bible  and  the  Flora 
f)f  Syria,  two  books  that  will  perpetuate  his  memory  in  the 
history  of  Syria  and  in  the  scientific  world.  When  Emperor 
IViiliam  visited  Beyriit  and  the  Johanniter  Hospital  he  was  made 


aware  of  what  Professor  Post  had  done  for  the  city,  the  coun- 
try, and  the  hospital,  and  it  was  a  gracious  and  timely  act  on 
his  part  when  he  conferred  upon  the  hard- worked,  faithful  pro- 
fessor the  decoration  of  the  Red  Eagle.  The  famous  Emperor 
never  conferred  a  decoration  upon  a  more  worthy  man.  Pro- 
fessor Post  is  a  model  of  what  a  medical  missionary  should  be. 
He  has  acquired  a  perfect  knowledge  of  the  language  of  the  coun- 
try of  his  choice.  He  never  fails  in  delivering  every  Sunday  a 
sermon  in  Arabic  to  the  patients  of  the  Johanniter  Hospital. 
Dr.  Post  has  visited  the  United  States  only  three  times  since 
he  gave  his  services  to  Syria.  It  is  for  good  reasons  that  the 
great  hall  of  science  in  connection  with  the  Syrian  Protestant 
College  should  be  called  the  Post  Hall,  a  recognition  to  which 
he  is  entitled  by  his  long  and  faithful  services  to  the  institution 
that  owes  so  much  to  his  untiring  efforts. 

Other  Hospitals.— The  Catholic  College  in  Beyrut  has  the 
same  objects  in  view  as  the  Protestant  College,  but  has  not  found 
the  same  degree  of  favor  with  the  natives.  The  French  and 
Greek  hospitals  take  care  of  the  subjects  of  the  respective 
countries,  and  will  do  their  share  in  disseminating  modern 
medicine  and  surgery  in  Asia. 

DAMASCUS. 

This  is  a  city  that  interests  every  biblical  student.  It  was 
made  famous  for  all  time  by  the  conversion  of  Saul.  The  place 
of  his  conversion  on  the  road  to  Jerusalem  and  the  house  of 
Ananias  he  visited  by  the  Lord's  request  are  the  two  places 
every  stranger  is  sure  to  visit.  The  city  is  much  the  same  as 
when  thi-^  incident  occurred.  Some  of  the  old  walls  that 
sheltered  it  from  invading  forces  at  that  time  still  remain. 
It  has  now  a  population  of  250,000  inha1)itants,  representing 
Syria  and  its  adjacent  countries.  Its  narrow  streets,  small 
shops  and  the  mass  of  ragged  citizens  speak  only  too  plainly  of 
its  poverty. 

Medical  Practice  in  Damascus. — Damascus  is  not  the  place 
for  the  physician  whose  principal  desire  is  to  accumulate 
wealth.  The  city  has  20  licensed  practitioners  besides  the 
military  surgeons  stationed  here,  who  are  permitted  to  practise 
their  profession  outside  their  military  duties.  Ten  cents  pays 
for  an  office  consultation,  and  two  to  three  francs  for  a  visit.  A 
large  majority  of  the  people  are  poor  and  cannot  pay  anything 
for  medical  services.  For  this  part  of  the  population  the  many 
medical  dispensaries  make  provision.  For  instance,  Dr. 
Alexander  Halabi,  a  physician  of  Arabian  origin,  has  charge  of 
the  Russian  Dispensary  and  cares  for  40  patients  daily,  a  service 
for  which  he  is  paid  80  francs  monthly.  Similar  dispensaries 
supported  from  other  sources  do  much  tOAvard  the  care  of  the 


sick  poor  of  Damascus.  I  know  of  no  other  city  in  which  the 
dispensary  service  does  more  good  than  in  Damascus.  Very 
few  emergency  cases  apply  to  dispensaries,  as  injuries  are  of 
very  rare  occurrence.  Smallpox  has  been  stamped  out  by  a 
strict  enforcement  of  the  vaccination  laws.  Diphtheria  is 
seldom  met.  Venereal  diseases  are  said  to  be  quite  common, 
and  among  the  natives  pursue  a  mild  course.  Among  the 
acute  diseases  typhoid  fever,  malaria  and  rheumatism  are  most 
prevalent.  Tuberculosis  of  joints,  bones  and  lymphatic  glands 
are  common  diseases  of  childhood. 

Damascus  Hospitals.— The  city  of  Damascus  has  only  three 
hospitals,  the  Municipal  or  city  hospital,  the  Military,  and  the 
A^ictoria  Hospital.  The  Municipal  Hospital  is  a  modern  build- 
ing with  a  capacity  for  100  patients  and  is  in  charge  of  military 
surgeons.  Provision  is  made  for  a  few  private  patients.  The 
furnishings  of  the  wards  are  all  that  could  be  desired.  The  small 
operating-room  is  supplied  with  everything  necessary  for  asep- 
tic work.  The  absence  of  trained  female  nurses  in  common 
with  most  of  the  public  Oriental  hospitals  is*  noticed  more  by 
the  transient  visitor  than  anything  else.  The  Military  Hospi- 
tal, with  500  beds,  is  an  old  building  in  the  very  heart  of  the 
city,  devoid  of  all  modern  improvements. 

The  VietoHa  Hospital. — This  is  the  old  Mission  Hospital, 
established  and  supported  by  a  Scottish  missionary  society. 
During  the  jubilee  year  of  Queen  Victoria  the  British  subjects 
of  Syria  raised  the  sum  of  £160  in  honor  of  the  occasion.  This 
sum  was  later  appropriated  to  the  use  of  the  hospital,  which 
then  assumed  the  name  of  Victoria  Hospital.  In  recognition 
of  this  devotion  the  Queen  sent  a  fine  steel  engraving  of  her- 
self to  the  institution ;  this  is  now  the  main  attraction  in  the 
reception-room.  The  hospital  can  take  care  of  41  patients  and 
is  in  charge  of  Dr.  Frank  Irving  Mackinnon,  a  graduate  of  the 
Edinburgh  school.  Dr.  Mackinnon  is  an  enthusiastic  mission- 
ary physician  and  he  has  done  much  and  will  do  still  more  in 
disseminating  modern  medicine  and  surgery  in  Asia. 

My  next  communication  will  treat  of  the  hospitals  in  Jeru- 
salem. The  nursing  is  in  charge  of  two  trained  Scotch  Sisters 
assisted  by  native  women.  A  few  private  rooms  are  reserved 
for  patients  who  are  able  to  pay.  The  hospital  was  opened  five 
years  ago.  The  surgical  patients  outnumber  the  medical.  A 
few  days  ago  the  first  case  of  ovarian  tumor  was  operated  upon. 
The  large  garden  with  tropical  trees  and  plants  is  a  charming 
place  for  the  recuperation  of  convalescents. 
Damascus,  June  24. 


IReprinted  from  American  Medicine  Vol.  IV,  No.  13,  pages  509-512, 
September  27,  1902.] 


THE  HOSPITALS  OF  JERUSALEM, 

BY 

N  ECHO  LAS  '^ENX,  M,D., 
of  Chicago. 

A  brief  description  of  the  hos^pital  facilities  of  the  ancient 
historic  city  of  Jerusalem  may  be  of  more  than  passing  interest 
to  the  medical  profession  of  our  country.  The  very  name 
Jerusalem  carries  our  memory  back  to  our  earliest  ciiildhood 
days.  The  great  events  which  occurred  in  that  city  and  so 
vividly  described  in  the  Sci-iptures  are  familiar  to  every  Sun- 
day-school scholar,  and  the  pictures  formed  of  them  in  the 
mind  of  the  child  remain  as  long  as  memory  lasts.  It  is  here 
where  the  greatest  miracles  were  performed  ;  where  the  Great 
Physician  taught  and  labored  ;  where  he  healed  the  lepers, 
made  the  blind  see,  the  deaf  hear,  and  the  lame  walk.  But 
Jerusalem  of  today  is  not  the  Jerusalem  of  those  days.  The 
magniticent  temple  of  Solomon,  the  pride  of  the  Holy  Land,  is 
no  more.  The  ruthless  hand  of  time  and  the  destruction 
wrought  by  war  and  fire  have  left  but  few  reliable  landmarks 
of  the  proud  city  of  Zion.  The  descendants  of  the  people  who 
V)uiltand  owned  it  have  been  reduced  to  a  condition  worse  than 
slavery.  The  Jews  of  the  Bible  clamored  for  the  cross ;  the 
Jews  of  today  are  held  in  subjection  and  are  persecuted  and 
humiliated  by  the  crescent.  They  occupy  the  narrowest,  most 
crowded,  and  filthiest  streets,  conduct  the  smallest  shops,  and 
furnish  the  largest  contingent  to  the  army  of  shoeblacks.  The 
large  group  of  wailiug  Jews  that  gathers  so  regularly  every  Fri- 
day afternoon  outside  of  what  was  once  the  city  wall  is  an  object 
lesson  which  when  once  seen  will  never  be  forgotten.  A  mot- 
ley crowd  of  men,  women  and  children,  with  Hebrew  Bible  in 
hand,  lean  against  the  wall  and  in  pitiable,  mournful  tones 
lament  their  loss  and  in  fervid  prayer  petition  the  God  of  Israel 
for  relief.  For  nearly  2,000  years  these  weekly  wailings  out- 
side the  walls  of  their  former  city  have  taken  place  with  great 
regularity,  but  their  position  in  life  remains  the  same.  David 
street  is  the  center  of  the  Jewish  settlement  and  it  would  be 
impossible  to  find  a  dirtier  thoroughfare,  less  inviting  stalls, 
and  more  odorous  human  habitations  anywhere.  The  present 
number  of  inhabitants  of  Jerusalem  is  150,000  and  of  these 
about  one-half  are  Jews.  The  lack  of  sewerage  and  the  scarcity 
of  water  account  for  many  of  the  prevailing  diseases.  Bathing- 
is  a  luxury  and  not  within  the  reach  of  the  poor.  In  one  of  the 
hospitals  I  was  informed  that  a  patient  recently  admitted  said 


that  she  had  not  had  a  bath  in  ten  years  and  from  what  I  saw 
in  the  Jewish  quarter  of  the  city  and  elsewhere  I  am  sure  this 
was  by  no  means  an  isolated  experience.  When  water  has  to  be 
bought  and  paid  for  out  of  the  lean  purse  of  poverty-stricken 
people,  the  supply  must  necessarily  be  a  limited  one.  Sewer- 
age and  an  ample  supply  of  wholesome  water  would  make  Jeru- 
salem the  most  healthful  city  in  the  Orient,  as  its  geographic 
location  is  an  excellent  one,  at  an  elevation  of  2,400  feet  above 
the  level  of  the  sea. 

HOSPITALS   OF  JERUSALEM. 

Jerusalem  has  for  a  long  time  been  a  center  of  mission 
work  in  w^hich  foreign  nations  and  different  religious  denomi- 
nations have  taken  an  active  interest.  The  extreme  poverty  of 
the  great  majority  of  its  inhabitants  and  the  unsanitary  condi- 
tion of  the  city  are  largely  responsible  for  the  unusually  large 
number  of  sick  poor.  The  different  hospitals  take  care  of  at 
least  1,000  outdoor  patients  every  day.  It  is  a  great  pity  that 
this  enormous  clinical  material  is  not  utilized  to  greater  advan- 
tage for  scientific  investigations.  The  oculist,  the  dermatolo- 
gist, and  the  genitourinary  surgeon  would  find  here  a  rich  field 
for  clinical  study.  The  hospitals,  some  12  in  number,  are  all 
small,  and  none  of  them  makes  any  pretension  to  being  entirely 
modern. 

The  German  or  Deaconess  Hospital. — This  is  the  best  hos- 
pital in  the  city.  It  is  one  of  the  many  hospitals  erected,  main- 
tained and  managed  by  the  Sisters  of  Kaisers werth  in  Ger- 
many.  This  order  of  German  nurses  has  labored  here  since 
1851  in  the  interest  of  the  sick  poor  of  all  nations.  The  present 
building  is  a  new  one  and  its  doors  are  wide  open  to  all  in  need 
of  medical  treatment,  at  the  same  time  ample  provisions  have 
been  made  for  private  patients.  Eight  faithful  Sisters  attend 
to  the  needs  of  the  patients  and  are  tireless  in  securing  the 
necessary  funds  to  carry  out  the  many  charitable  objects  of  the 
institution.  During  the  visit  of  the  German  Emperor  to  Jeru- 
salem the  Empress  honored  the  hospital  by  a  visit.  What 
attracted  her  attention  most  was  the  imperfect  supply  of  instru- 
ments and  facilities  for  aseptic  work  in  the  operating-room. 
She  dictated  an  order  for  everything  necessary,  sent  it  to  Ger- 
many, and  the  hospital  has  now  the  best  equipped  operating- 
room  in  Palestine,  all  at  her  private  expense.  Visits  like  these 
live  in  the  history  of  any  charitable  institution.  The  hospital 
is  located  in  a  quiet  part  of  the  city  and  can  accommodate  60 
patients.  The  outdoor  department  is  visited  by  more  than  5,000 
patients  every  year.  The  relative  proportion  of  the  different 
nationalities  of  the  inmates  for  the  year  1898  was  as  follows  : 
Arabs,  698;  Armenians,  54;  Germans,  45;  Greeks,  14;  Aus- 
trians,  12  ;  Bulgarians,  3 ;  English,  Swiss  and  Spaniards,  each,  2  ; 


8 


I  American  and  1  Rnssian.  The  institution  is  constantly  grow- 
ing in  favor  with  the  natives  and  its  far-reaching  influence,  as  a 
center  of  true  charity  and  as  a  house  of  refuge  for  visitors 
stricken  down  with  disease,  cannot  be  overestimated. 

The  Russian  IfospitaL—This  hospital  is  supported  by  the 
Russian  government  and  a  local  branch  of  the  Red  Cross.  It 
can  accommodate  44  patients,  and  in  a  separate  building  there 
are  ten  additional  beds  for  patients  suffering  from  acute  infec- 
tious diseases.  The  arched  corridors  and  rooms  correspond 
in  archit  cture  with  many  of  the  more  important  buildings, 
public  and  private,  in  Jerusalem.  The  sick  are  under  the  care 
of  two  Russian  Red  Cross  Sisters.  The  dispensary  is  large  and 
in  charge  of  two  competent  druggists.  The  small  operating- 
room  contains  all  that  is  essential  for  modern  surgical  work. 
The  outdoor  department  is  popular  with  the  mass  of  the  people, 
as  it  WIS  visited    bv  22,000  patients   daring  the  last  year.     Dr. 


Gennau  Deaconess'  Hospital  in  Jerusalem. 

Severine  is  the  only  medical  attendant.  He  is  a  Greek,  studied 
in  Athens  and  after  graduation  spent  two  years  in  Paris.  In  his 
outdoor  work  he  sees  many  cases  of  furunculosis,  abscess, 
lymphangitis  and  erysipelas.  In  the  operating-room  he  relies 
on  chloroform  as  an  anesthetic,  and  silk  as  suture  and  ligature 
material.  The  hospital  is  open  for  all  deserving  sick  poor, 
regardless  of  nationality  or  religious  faith.  During  my  visit  I 
was  shown  three  cases  of  empyema  recently  operated  upon  by 
the  radical  method.  In  all  of  these  cases  the  suppurative 
pleuritis  developed  in  the  course  of  croupous  pneumonia. 

The  Greek  Hospital.— This  hospital  was  established  by  the 
Greek  Catholic  Church  in  1865.  It  has  54  beds,  many  of  which 
are  occupied  by  pilgrims,  who  come  annually  in  large  numbers 
to  Jerusalem  and  who  are  taken  ill  on  the  way.  Dr.  Nicholas 
Spyridon  is  the  medical  director.  During  the  last  10  years  he 
has  performed  laparotomy  for  echinococcus  cyst  twice  ;  one  of 
the  patients  died,  the  other  recovered. 


Hospital  of  Saint  7>o?tM.— This  hospital  Avas  built  by  and  is 
in  charge  of  the  Sisters  of  St.  Joseph,  who  came  to  Jerusalem  52 
years  ago.  The  present  excellent  building  is  22  years  old  and 
has  a  capacity  of  85  beds.  It  is  a  solid  stone  building  two  and 
three  stories  high,  with  a  large  open  court  in  the  rear  orna- 
mented with  trees,  flowering  shrubs  and  flowers.  The  wards 
are  large,  well  lighted  and  scrupulously  clean.  The  comfort- 
able beds  and  spotless  linen  contribute  much  to  the  general 
attractiveness  of  the  sick-rooms.  The  hospital  is  in  the  very 
heart  of  the  city  and  is  enclosed  by  a  high  stone  wall.  On  an 
average  300  patients  call  at  the  outdoor  department  every  day. 
Two  physicians  are  in  charge  of  the  medical  and  surgical  seiv- 


Operating-rooni  in  Russian  Hospital,  Jerusalem. 


ice.  The  Sisters  assist  in  operations  and  apply  many  of  the 
dressings.  One  of  the  Sisters,  a  graduate  in  pharmacy,  is  in 
charge  of  the  large  dispensary.  As  all  of  the  patients,  indoor 
and  outdoor,  are  charity  cases,  it  is  a  source  of  surprise  to  the 
visitor  to  see  the  institution  in  such  a  flourishing  condition. 
The  prayers  of  these  hard-working,  unselfish  Sisters  must  find 
a  ready  response  from  somewhere. 

Hospice  of  the  Sisters  of  Charity,  St.  Vincent  de  Paul.— This 
is  not  a  hospital  proper,  but  a  home  for  the  blind,  the  crippled, 
the  incurables,  the  aged  and  the  orphans.  It  is  a  charitable 
institution  in  the  widest  sense  of  the  word.  Seventeen  Sisters 
labor  here  night  and  day  to  render  life  comfortable,  and  when 
it  can  be  done,  useful.    It  contains  at  present  170  inmates.    One 


5 


of  the  Sisters  educates  the  blind  children,  another  takes  care  of 
the  many  infant  orphans,  a  third  one  conducts  a  school,  while 
others  are  engaged  in  making  life  endurable  for  the  incurables. 
Here  is  a  profitable  and  grateful  place  for  modern  surgery.  The 
sight  of  many  of  the  blind  could  be  restored  and  many  of  the 
crippled  limbs  could  be  made  useful  by  surgical  intervention. 
Let  ns  hope  that  the  Sisters  may  find  the  gratuitous  services  of 
a  competent  oculist  and  surgeon  to  aid  them  in  their  philan- 
thropic work. 

Baron  Rotlischill  Hospital.— This  charitable  establishment 
was  founded  49  years  ago  by  the  Rothschild  family,  and  was 
intended  exclusively  for  the  benefit  of  the  Jewish  population  of 
the  city.  The  present  site  M^as  selected  and  the  hospital  built  in 
1885.  The  hospital  space  is  limited  to  12  beds  for  men,  an  equal 
number  for  wonien  and  six  for  children.  Only  Jews  are 
admitted  into  the  hospital,  while  the  outdoor  clinic  is  open  to 
all  who  apply.  There  are  no  private  rooms,  and  all  expenses 
are  paid  from  a  fund  donated  by  the  founders  of  the  institution. 
Sick  mothei'S  often  bring  their  infant  children  with  them,  and 
sick  children  are  equally  often  accompanied  by  their  mothers. 
The  facilities  for  surgical  work  are  very  primitive,  as  very  few 
operations  are  performed.  Dr.  I.  G.  D.  Arbelie  is  the  attending 
physician  and  at  the  same  time  conducts  the  outdoor  depart- 
ment, to  which  not  infrequently  as  many  as  325  patients  apply  a 
day.  The  doctor  is  an  Italian  by  birth  and  education,  but  spent 
several  years  in  Paris  after  his  graduation.  He  speaks  and 
writes  16  languages,  and  has  use  for  them  all  every  day  in  con- 
versing with  his  outdoor  patients.  He  is  a  tireless  worker. 
His  professional  work  often  extends  beyond  the  midnight 
hour.  The  number  of  malarial  cases  he  is  called  upon  to  treat 
may  be  approximately  estimated  from  the  statement  he  made 
to  me  that  he  uses  annually  no  less  than  40  kilos  of  quinin.  In 
severe  cases  of  malaria  treated  in  the  hospital  he  preferred  to 
use  this  drug  by  subcutaneous  injections  ;  in  the  outdoor  clinic 
it  is  administered  in  pill  or  powder  form.  At  the  time  of  my 
visit  nearly  all  the  beds  were  occupied  by  malaria  patients. 
Pronounced  anemia,  enlargement  of  the  spleen  and  liver  and 
ascites  from  the  last  two  affections  were  the  most  frequent 
remote  malarial  complications.  In  the  hospital  a  small  syna- 
gogue serves  as  a  place  of  worship  for  the  orthodox  Jews. 

Municipal  Hosjyital. — Besides  the  military  hospital  this  is 
the  only  government  hospital.  It  was  built  15  years  ago,  has  30 
beds  and  is  beautifully  located  on  the  highest  hill  in  the  city. 
The  hospital  is  well  furnished  and  the  little  operating-room  has 
been  renovated  recently  and  is  supplied  with  all  facilities  for 
aseptic  work.  The  question  of  nationality  and  religion  is  not 
considered  in  admitting  patients.    The  outdoor  clinic  of  this 


hospital,  which  is  a  very  large  one,  is  in  the  central  and  most 
accessible  part  of  the  city.  A  few  years  ago  a  radical  change 
for  the  better  was  made  in  the  nursing  force  by  placing  the 
patients  in  charge  of  three  Sisters  of  Charity.  The  initiation  of 
these  Sisters  into  their  work  in  a  Turkish  government  hospital 
was  an  important  event  and  the  ceremony  was  attended  by  the 
ruling  Pacha  and  military  officers  of  high  rank.  The  Sisters 
sleep  in  their  own  hospice  and  the  only  remuneration  they 
receive  for  their  services  is  60  piastres  (or  $8.00)  a  month,  just 
enough  to  pay  for  carriage  hire.  It  is  needless  to  say  that  the 
patients  appreciate  to  the  fullest  extent  the  kind  and  skilful 
nursing  of  these  faithful  and  devoted.  Sisters.  Dr.  Photios,  a 
Greek  physician,  has  charge  of  the  medical  service.  He  is  a 
man  of  far  more  than  average  intelligence  and  ability  and  is 
devoted  to  his  profession  and  his  patients. 

Jesus-Hilfe.— This  is  an  asylum  for  the  care  of  lepers.     At 
present  the  number  of  lepers  in  Palestine  is  estimated  at  from 


I  _«aLjaB!ffi»^  C:  LC^'W^^j^/',!^^^-^  -^  I- 


Jesus-Hilfe  Leper  Asylum. 

300  to  400.  These  unfortunates  form  a  large  part  of  the  profes- 
sional beggars  in  the  streets  of  Jerusalem.  They  have  formed 
an  organization  among  themselves  with  a  chief  of  their  own 
selection  at  the  head  for  the  purpose  of  making  begging  more 
systematic  and  remunerative.  These  lepers  mix  freely  with  the 
people  in  the  streets  and  public  places.  Most  of  the  lepers  are 
Arabs,  the  Jews  are  singularly  exempt  from  this  disease.  The 
tubercular  and  anesthetic  forms  are  about  equally  represented. 
Many  years  ago  the  Moravian  Brotherhood  at  Herrnhut,  Ger- 
many, conceived  the  happy  idea  of  taking  care  of  the  lepers  in 
Palestine.  In  1886  the  present  building,  some  two  miles  from 
the  city  limits,  was  completed.  It  was  found  very  difficult  to 
induce  the  lepers  to  enter  and  remain  in  this  excellent  institu- 
tion, erected  for  their  special  benefit.  They  hesitated  in 
exchanging  their  roaming  free  outdoor  life  for  a  pleasant  home 
in  the  asylum.  In  many  instances  they  would  remain  for  a 
short  time  and  then  leave  suddenly  without  permission  and 
resume  their  begging  station  in  the  most  frequented  streets; 


8 


when  their  business  did  not  thrive,  when  their  scanty  gar- 
ments became  ragged  and  finally  when  hunger  tortured  them 
they  would  return  to  their  former  hospitable  asylum  home  and 
remain  long  enough  to  satisfy  their  immediate  wants  and  then 
disappear  again  as  suddenly  and  unceremoniously  as  before. 
Gradually,  however,  the  confidence  in  their  benefactors 
increased  and  they  realized  more  and  more  the  unselfish  benefi- 
cence of  the  institution.  At  present  the  asylum  contains  47 
inmates.  It  is  conducted  in  a  most  economic  manner,  but  the 
patients  are  well  fed,  comfortably  clothed  and  receive  the  most 
tender  care.  The  asylum  is  presided  over  by  Mr.  Charles 
and  Mrs.  Annie  Schubert,  and  the  patients  are  cared  for  by 
Deaconesses  Ehrle,  Eisner,  Miiller  and  Zimmer.  Dr.  Einsler, 
the  physician-in-chief  of  the  Deaconess  Hospital,  directs  tlie 
hygienic  and  medical  treatment.  The  serum  treatment  was 
made  use  of  in  a  number  of  cases,  but  the  high  fever  caused  by 
the  injections  aggravated  the  disease  and  in  a  few  cases  hast- 
ened the  fatal  termination.  Among  the  47  inmates  of  the 
asylum  there  is  only  one  Jew.  Dr.  Einsler,  during  his  long 
and  extensive  practice  in  Jerusalem,  has  seen  only  three  Jews 
affected  with  leprosy,  and  of  these  one  came  from  Salonik  and 
the  remaining  two  from  Morocco.  It  seems  then  that  the  Jews 
of  Jerusalem  have  in  the  course  of  time  acquired  an  immunity 
against  this  disease  notwithstanding  the  increase  of  poverty 
and  unsanitary  surroundings.  The  Jesus-Hilfe  leper  asylum 
of  Jerusalem  is  one  of  the  most  deserving  charitable  institu- 
tions of  Jerusalem  and  deserves  the  financial  support  of  all 
humanitarians. 

British  Hospitals,— The  English  people  have  done  their 
good  share  in  the  alleviation  of  the  suffering  poor  of  Jerusalem. 
One  of  these  hospitals,  the  Ophthalmic,  is  devoted  exclusively 
to  the  treatment  of  diseases  of  the  eye;  the  other  is  a  general 
hospital.  Eye  affections  are  alarmingly  common  in  Jerusalem 
and  throughout  Palestine.  In  no  other  city  are  the  blind  more 
numerous  and  inflammatory  affections  so  common.  Bulbless 
sockets  and  opaque  corneas  are  met  every  few  steps  in  any  of 
the  crowded  streets.  Specific  infection  and  trachoma  are  the 
most  frequent  causes  of  blindness.  The  number  of  blind 
infants  and  young  children  is  astonishing.  The  Ophthalmic 
Hospital  has  20  endowed  beds,  which  are  always  in  great 
demand.  Three  times  a  week  the  outdoor  department  is 
thronged  with  men,  women  and  children  who  apply  for  relief. 
This  hospital  has  a  Avide  range  of  usefulness  in  averting  blind- 
ness and  in  restoring  sight  in  cases  adapted  for  successful 
operative  interference. 

Jerl'salem,  July  1. 


[Reprinted  from  American  Medicine.  Vol.  IV,  No.  14  pages  550-552. 
October  4, 1902.] 


MEDICAL  PRACTICE  IN  CAIRO  AND  PREVAILING 
DISEASES  OF  EGYPT. 

BY 

NICHOLAS  SENN,  M.D., 

of  Chicago. 

The  name  of  Egypt  brings  up  thoaglits  of  antiquity.  The 
land  of  the  Rauieses,  of  the  Pharaohs,  has  a  history  the  begin- 
ning of  which  extends  back  to  the  dark  unknown— Egypt,  the 
most  famous  of  ancient  nations,  once  the  center  of  science,  art, 
literature  and  commerce  and  which  remains  much  the  same  as 
it  was  more  than  two  thousand  years  ago.  Tlie  Pyramids 
remain  as  silent  witnesses  of  the  power  and  ambition  of  its 
earliest  rulers  and  the  waters  of  the  same  lordly  Nile  continue 
to  irrigate  its  fertile  valleys.  In  the  course  of  time,  science  and 
art  fled  to  foreign  countries  and  the  greatest  commercial  cen- 
ters have  arisen  in  countries  which  were  unknown  when  the 
glory  of  Egypt  was  the  envy  of  the  world.  The  Egyptian 
works  of  art  have  found  places  in  the  large  museums  through- 
out the  world.  The  royal  tombs  have  been  robbed  and  their 
precious  contents  are  on  exhibition  in  strange  lands,  strong 
reminders  of  the  limitation  of  life  and  vanity  of  earthly 
power.  Egypt  was  the  cradle  of  the  healing  art.  For  centuries 
Alexandria  was  the  mecca  for  medical  students.  Its  great 
library  attracted  the  scientific  men  from  far  and  near.  The 
Arabic  medical  textbooks  were  accepted  as  authoritative  every- 
where and  formulated  the  practice  of  all  pliysicians  who  made 
any  claim  whatever  to  education.  With  the  gradual  decay  of 
Egypt  progress  in  medicine  declined,  but  today  the  profession 
of  the  western  medical  world  is  returning  to  the  ancient  center 
of  medical  education  in  a  new  and  much  improved  form  what 
was  borrowed  centuries  ago.  So  great  have  been  the  advance- 
ments in  medicine  during  that  time  that  the  Arabic  language, 
the  medical  language  for  many  ages,  has  become  utterly  inade- 
quate to  express  modern  medical  ideas.  Cairo  is  the  door 
through  which  scientific  medicine  is  finding  its  way  again  into 
the  land  where  civilization  had  its  dawn. 

CAIRO   AS   A   MEDICAL   CENTER. 

Cairo  is  the  largest  city  in  Africa.    Its  present  population  is 
nearly  1,000,000.    Located  in  the  fertile  valley  of  the  Nile,  on 


the  banks  of  this  great  waterway  through  Egypt  and  near 
Alexandria,  the  great  seaport  town  of  the  western  coast  of 
Africa,  it  continues  to  cotnmand  an  important  position  in  the 
commercial  world.  The  genial  winter  climate  has  made  it  also 
a  desirable  and  fashionable  health  resort.  The  city  has  a  num- 
ber of  first-class  hotels,  and  daring  the  winter  months  is 
crowded  with  wealthy  visitors  from  all  parts  of  the  world 
who  seek  recreation  or  a  climate  conducive  to  their  health. 
Tbe  European  part  of  the  city  has  fine  residences,  beautiful 
gardens,  magnificent  streets  and  boulevards,  and  is  well 
policed.  Begging,  the  curse  of  the  Palestine  cities,  does  not 
prevail,  and  the  natives  treat  the  strangers  with  respect  and 
courtesy.  Modern  medicine  has  gained  a  firm  foothold  in 
Cairo  and  Alexandria.  More  than  100  European  physicians 
have  located  here  and  practice  their  profession  with  variable 
success. 

Medical  Pyac</ce.— Egypt  does  not  suffer  from  a  lack  of 
physicians.  The  country  has  10,000,000  inhabitants,  and  there 
are  from  1,000  to  12,000  physicians  in  readiness  to  respond  to 
professional  calls.  As  at  least  75%  of  the  patients  are  unable 
to  pay  for  medical  services,  and  as  the  competition  in 
the  two  large  cities,  Cairo  and  Alexandria,  is  keen,  it  is  a 
natural  consequence  that  the  fees  should  be  small.  Few 
physicians  in  Cairo  receive  on  an  average  more  than  a  dollar 
a  visit  and  50  cents  for  an  office  consultation.  Surgical  work 
is  better  paid  for,  but  $150  is  considered  a  handsome  fee  for  any 
of  the  major  operations.  What  makes  surgery  in  Egypt  not 
more  remunerative  is  the  inborn  aversion  of  the  natives  to 
surgical  operations.  This  aversion  amounts  almost  to  absolute 
refusal  among  the  Mohammedan  Avomen.  This  is  the  reason 
why  ovariotomy  and  hysterectomy  figure  so  low  in  all  hospital 
statistics.  The  Arabs  bear  surgical  operations  well.  Shock 
and  accidents  from  the  administration  of  anesthetics  are  very 
i-are.  The  natives  are  grateful  patients  and  never  forget  the 
services  of  their  physician.  Of  this  I  saw  an  instance  in  the 
Municipal  Hospital,  Cairo.  As  we  were  passing  through  one 
of  the  wards  a  man  with  a  tracheotomy  tube  in  his  trachea 
approached  Dr.  Wildt,  who  accompanied  me,  prostrated  him- 
self and  kissed  his  feet.  The  doctor  explained  that  the  man 
was  a  former  patient  of  his  at  a  time  when  carcinoma  of  the 
thyroid  gland,  which  later  made  the  tracheotomy  necessary, 
was  still  within  reach  of  a  successful  naedical  operation. 
Excision  of  the  carcinomatous  gland  was  proposed,  but  was 
promptly  refused.  In  the  meantime  experience  demonstrated 
to  the  patient  only  too  plainly  the  correctness  of  his  physician's 
diagnosis  and  the  wisdom  of  his  advice. 

The  entrance  into  practice  in  Egypt  is  not  difficult,  all  that 


is  necessary  is  to  present  a  diploma  from  any  recognized  medi- 
cal college.  The  graduates  of  the  medical  college  in  Bey  rut  are 
permitted  to  practise  on  a  certificate  from  that  school.  Consid- 
ering the  number  of  physicians  already  in  the  country  it  would 
seem  advisable  and  timely  to  make  the  laws  governing  the 
entrance  into  practice  more  stringent. 

Medical  Societies.— Y.gyY>i  has  at  present  two  medical 
societies,  one  in  Cairo  the  other  in  Alexandria.  The  Cairo 
Medical  Society  has  a  membership  of  60,  and  meetings  are  held 
every  three  weeks  during  the  winter  season.  At  these  meet- 
ings modern  surgical  and  medical  topics  are  discussed  and 
clinical  cases  and  pathologic  specimens  are  exhibited.  The 
Egyptian  Medical  Congress  will  be  held  in  Cairo  next  Decem- 
ber. This  congress  is  called  for  the  special  purpose  of  discuss- 
ing tropical  diseases,  and  is  international  in  its  scope.  Invita- 
tions have  been  sent  to  all  countries,  and  there  are  fair  prospects 
for  a  good  attendance. 

Dr.  H.  Wildt  will  present  an  exhaustive  paper  on  "  The 
Surgical  Aspects  of  Bilharzia."  His  immense  experience 
entitles  him  to  speak  authoritatively  on  this  subject.  Professor 
Bitter,  of  the  Hygienic  Institute,  will  discuss  "  Madura  Foot." 
As  the  professor  has  made  a  special  study  of  the  parasite  of  this 
strange  disease  for  a  year  and  a  half  the  audience  may  expect  to 
learn  all  that  is  known  of  the  etiology  and  pathology  of  this  rare 
disease. 

The  Egyptian  colleagues  ought  to  utilize  this  opportunity 
and  organize  a  national  society.  The  annual  work  of  such  a 
society  would  be  of  the  greatest  value  in  enlightening  the  medi- 
cal profession  throug.hout  the  entire  world  on  many  of  the 
tropical  diseases,  the  nature  of  which  as  yet  is  but  imperfectly 
understood. 

Cairo  Medical  College.— This  is  the  only  school  in  Egypt 
devoted  to  the  study  of  medicine.  It  is  fairly  well  equipped, 
and  is  attended  during  the  present  year  by  60  students.  Nearly 
all  of  the  professors  are  Englishmen,  a  few  natives  fill  subordi- 
nate positions.  The  students  must  study  four  years  before 
they  are  admitted  to  the  linal  examinations.  The  clinical 
teaching  is  conducted  in  the  Municipal  Hospital  by  a  large 
staff  of  professors  and  instructors,  most  of  them  of  English 
birth  and  education.  As  the  classes  are  small  and  the  clinical 
material  abundant,  this  part  of  instruction  is  all  that  could  be 
desired. 

Kasr-el-Ainj/  Hospital. — This  is  the  municipal  or  govern- 
ment hospital.  It  is  an  old  building  which  has  recently  been 
much  improved  to  answer  modern  requirements.  It  contains 
400  beds.  All  the  expenses  are  paid  l)y  the  government,  and 
admission  is  free  to  all  sick  poor.    The  wards  are  large,  airy 


and  well  lighted.  The  hospital  furnishings  are  plain,  but  com- 
fortable and  sanitary.  The  two  operating-rooms  are  fairly  well 
equipped.  One  is  used  for  surgical,  the  other  for  gynecologic 
cases.  Here  I  was  given  an  opportunity  to  examine  an  unusu- 
ally large  number  of  bilharzia  cases.  In  several  patients  the 
disease  had  resulted  in  the  formation  of  perineal  fistula,  in 
others  the  kidneys  had  become  involved.  The  ophthalmic  ward 
contained  the  usual  large  percentage  of  eye  cases.  Among  the 
other  tropical  diseases  I  noticed  elephantiasis,  ankylostoma 
and  a  large  number  of  pellagra  cases.  The  latter  presented, 
without  exception,  the  characteristic  eruption.  In  one  case  the 
disease  was  complicated  by  a  partial  dementia,  but  whether 


Deaconess'  Victoria  Hospital  in  Cairo. 


this  brain  defect  was  a  coincidence  or  the  result  of  the  original 
disease,  it  was  impossible  to  determine.  I  was  informed  that 
in  pellagra  cases  ankylostoma  is  very  common.  All  of  the 
pellagra  patients  showed  distinct  signs  of  anemia.  The  nurs- 
ing is  in  the  hands  of  nine  trained  female  nurses  from  England. 
This  hospital  could  make  itself  still  more  useful  to  the  commu- 
nity by  the  establishment  of  a  training  school  for  native  women. 
The  Victoria  Deaconess^  Ho spi t a L— This  is  a  German  hos- 
pital founded  and  conducted  by  Sisters  from  Kaiserswerth.  It 
is  by  far  the  best  hospital  in  Cairo.  It  was  built  20  years  ago 
and  can  accommodate  100  patients.    At  present  nine  Sisters  are 


on  duty.  The  operating-room  is  modern  and  is  amply  supplied 
with  instruments  and  appliances  for  aseptic  work.  Dr.  H. 
Wildt  is  in  charge  of  the  surgical  service  and  is  assisted  by  the 
resident  physician,  a  graduate  of  a  German  university.  All  of 
the  patients  are  expected  to  pay.  They  are  divided  into  three 
classes.  The  first  class  pays  $2  a  day,  for  which  sum  they  are 
entitled  to  a  private  room.  The  second  class  pays  ^i  a  day 
and  live  in  rooms  with  two  or  three  beds.  The  ward  patients 
pay  very  little  and  those  that  are  very  poor  are  admitted  free. 
At  the  time  of  my  visit  Dr.  Wildt  showed  me  two  cases  of 
liver  abscess  recently  operated  upon  and  eight  cases  of  bilharzia 
presenting  the  various  clinical  phenomena  of  tlie  different 
stages  of  this  disease. 

It  is  interesting  to  note  the  cosmopolitan  character  of  the 
inmates  of  this  hospital  as  giveu  in  a  report  for  last  year. 

The  nationalities  of  the  patients  were  as  follows : 

Egyptians,  259;  British,  140;  Greeks,  86;  ( Germans,  64; 
Italians,  46  ;  Armenians,  46  ;  Austrians,  17  ;  Syrians,  18  ;  Swiss, 
14;  French,  12;  Americans,  7;  Berbereens,  7;  Russians,  5; 
Turks,  3;  Roumanians,  2  ;  Dutch,  2;  Indians,  1 ;  Soudanese,!; 
Abyssinians,  1 ;  Spaniards,  I ;  Persians,  1 ;  Belgians,  1 ;  South 
Africans,  1. 

PREVAILING  DISEASES   OF   EGYPT. 

The  government  of  Egypt  (England,  of  course)  has  taken  the 
necessary  steps  and  gone  to  the  requisite  expense  to  establish  an 
institution  which  is  intended  to  serve  the  purpose  of  offering  all 
necessary  facilities  for  the  scientific  study  of  infectious  diseases, 
with  a  special  view  to  more  thorough  investigation  of  tropical 
diseases  and  of  formulating  and  enforcing  effective  sanitary 
measures  by  building  and  maintaining  the  Hygienic  Institute. 

The  Hygienic  l7istitute.— This  building  is  located  in  the 
central  part  of  Cairo.  The  building  is  a  creditable  one  and  is 
well  supplied  with  all  necessary  facilities  for  bacteriologic  and 
pathologic  research.  It  was  opened  five  years  ago  under  the 
directorship  of  Professor  H.  Bitter,  a  German  scientist.  Profes- 
sor Bitter  is  the  right  man  in  the  right  place.  He  was  a  pupil 
of  Koch  and  other  distinguished  German  bacteriologists,  and 
for  several  years  was  privatdocent  in  the  Breslau  University. 
He  is  well  prepared  for  his  manifold  duties  and  commenced  his 
work  with  an  enthusiasm  characteristic  of  the  German  scien- 
tists. He  possesses  all  the  qualifications  for  the  position  he 
now  occupies.  He  is  an  expert  bacteriologist  and  pathologist, 
an  artist  and  skilful  photographer.  Since  he  has  taken  charge 
of  the  institute  he  served  as  a  member  of  a  commission  of  three 
appointed  by  the  government  to  visit  Bombay  for  the  purpose 
of  studying  the  bubonic  plague,  which  was  raging  in  India  at 
the  time  (1897).    He  published  the  results  of  his   far-reaching 


observations  in  a  paper  entitled  "  On  Haffkine's  Preventive 
Inoculations  Against  the  Plague  and  on  Plague  Measures  in 
India."  This  paper  appeared  in  1899  and  has  been  very  exten- 
sively noticed  in  the  medical  press  of  Europe  and  America.  He 
is  now  engaged  in  investigating  the  fungus  of  madura  foot  and 
its  effects  on  the  tissues.  He  makes  the  final  diagnosis  in 
obsure  cases  in  which  the  use  of  the  microscope  is  essential  in 
ascertaining  the  bacterial  nature  of  the  disease.  He  makes 
thorough  investigations  of  the  water  supply  in  various  parts  of 
Egypt  and  locates  the  source  of  infection  in  endemic  outbreaks 
of  infectious  diseases.  He  is  also  professor  of  hygiene  in  the 
Cairo  Medical  School. 

ACUTE   INFECTIOUS   DISEASES. 

Bubonic  Plagite.~At  the  present  time  there  are  no  cases  of 
bubonic  plague  in  Cairo.  The  disease,  however,  has  infested 
nine  or  ten  of  the  surrounding  villages  and  every  few  days  new 
cases  are  reported  from  Alexandria.  The  Syrian  ports  enforce 
quarantine  against  Alexandria.  Active  measures  are  being 
enforced  to  arrest  further  spread  of  the  disease. 

Malaria. — This  is  very  rare  in  Egypt.  In  Cairo  it  is 
almost  unknown  and  it  is  very  uncommon  in  the  valley  of  the 
Xile.  The  only  place  in  Egypt  where  malaria  is  engendered  to 
any  considerable  extent  is  along  the  banks  of  the  Suez  Canal 
and  a  few  other  isolated  places.  Malaria  is  the  prevailing  dis- 
ease throughout  Palestine,  more  especially  Jerusalem  and  its 
surrounding  villages.  Professor  Bitter  explains  this  on  the 
mosquito  theory.  He  says  the  mosquito  of  the  Xile  valley  is 
the  ordinary  culex,  while  the  mosquito  of  the  plains  and  moun- 
tains of  Palestine  is  the  Plasmodium  carrier — the  anopheles.  I 
had  a  bitter  experience  with  the  latter.  In  Jerusalem  and 
Damascus  they  attacked  viciously  my  hands  and  forearms. 
Swelling,  redness  and  lymphangitis  ensued,  which  caused  an 
intolerable  itching  and  burning,  rendering  sleep  impossible  for 
several  nights.  I  considered  it  advisable  to  take  a  daily  dose  of 
10  grains  of  quinin  to  prevent  the  development  of  malaria,  and 
so  far  this  prophylactic  treatment  appears  to  have  been  success- 
ful. I  am  satisfied  that  the  sting  of  this  kind  of  mosquito  is 
more  virulent  than  that  of  the  common  culex. 

Typhoid  i^eyer.— Typhoid  fever  is  the  great  scourge  of  Cairo 
and  many  other  parts  of  Egypt.  In  Cairo  it  is  never  absent. 
In  the  Victoria  Hospital  109  cases  were  treated  during  the  last 
year,  with  12  deaths.  The  shallow  infected  wells  are  the  breed- 
ing places  of  Bacillus  typhosus. 

Other  Acute  Infectious  Diseases. — Dysentery,  rheumatism 
and  acute  inflammatory  affections  of  the  lungs  and  air  passages 
figure  heavily  in  the  hospital  records  and  the  case-books  of 


physicians.  Pulmonary  tuberculosis  and  tuberculosis  of  the 
lymphatic  glands,  bones  and  joints  occur  with  the  same  fre- 
quency as  in  our  country.  The  same  can  be  said  of  smallpox, 
scarlatina  and  diphtheria. 

Bilharzia. — The  frequency  with  which  this  parasitic  disease 
prevails  in  Egypt  became  apparent  to  me  from  the  number  of 
cases  I  saw  in  the  Victoria  and  Municipal  Hospitals.  The  para- 
site enters  through  the  skin,  locates  in  the  radicles  of  the  portal 
A'ein,  in  the  wall  of  the  rectum  or  bladder.  The  ova  develop  in 
the  submucosa  of  the  rectum  or  bladder,  cause  ulceration  and 


Madura  Foot  (after  Bitter). 


often  the  formation  of  large  granulomatous  swellings.  If  the 
disease  invades  the  bladder  the  earliest  symptom  is  a  slight 
hemorrhage  after  urination,  followed  sooner  or  later  by  vesical 
and  urethral  irritation.  Extensive  ulceration  of  the  mucous 
membrane  of  the  urethra  results  in  periurethral  infiltration  and 
the  formation  of  a  perineal  fistula.  Not  infrequently  the  dis- 
ease ascends  along  the  ureter  and  ultimately  leads  to  pyelitis 
and  pyonephrosis.  The  bilharzia  cystitis  often  gives  rise  to  the 
formation  of  multiple  calculi.  Perineal  section  and  suprapubic 
cystotomy  are  often  made  necessary  by  extensive  disease  of  the 


urethra  and  bladder.  In  rectal  bilharzia  perineal  abscesses  and 
fistulas  are  the  remote  complications.  Dr.  Wildt  has  found  tur- 
pentine the  most  effective  remedy  for  internal  medication. 

A  nkylostoma  Duodenalis. — This  parasitic  affection  of  tlie 
intestinal  canal  is  very  common  in  all  parts  of  Egypt.  The 
most  common  symptom  is  a  pronounced  anemia.  In  the  Kars- 
el-Ainy  Hospital  thymol  has  been  found  the  most  effective 
remedy.  This  drug  is  administered  in  a  single  dose  of  two 
grams  followed  by  a  castor-oil  purge.  After  the  expulsion  of 
the  parasite  iron  is  given  to  correct  the  anemia. 

Madura  i^oo^— This  parasitic  disease  is  quite  rare  in 
Egypt.  Dr.  Wildt  has  seen  only  two  cases  in  23  years.  Last 
year  only  one  case  was  observed  in  the  Kars-el-Ainy  Hospital. 
The  parasite  is  a  ray  fungus  which  morphologically  bears  a 
close  resemblance  to  the  actinomyces.  The  swelling  of  the  foot 
is  almost  typical.  The  plantar  surface  gradually  changes  from 
a  concave  to  a  convex  shape.  The  nodules  in  the  skin  are 
composed  almost  exclusively  of  a  pure  culture  of  the  fungus. 
Two  varieties  occur,  the  w^hite  and  the  black.  In  the  latter 
variety  the  fungus  is  coal  black.  The  intlammatory  swelling 
consists  of  granular  tissue,  which  under  the  microscope  might 
readily  be  mistaken  for  a  small  round-cell  sarcoma. 

Abscess  of  the  Liver. — In  the  tropics  this  disease  is  not 
necessarily  preceded  by  dysentery  or  any  other  grave  lesions  of 
the  intestinal  canal.  Its  bacteriologic  origin  remains  unex- 
plained. When  Professor  Koch  was  in  Cairo  in  1883  he  made  a 
careful  bacteriologic  study  of  the  contents  of  a  number  of 
abscesses  of  the  liver,  but  was  unable  to  come  to  positive  con- 
clusions regarding  the  essential  bacteriologic  cause.  Xo  more 
definite  results  have  been  reached  since.  I  had  an  opportunity 
to  see  two  cases  of  this  affection  in  the  Victoria  Hospital.  The 
patients  were  recently  operated  upon  by  Dr.  Wildt.  In  one  case 
the  abscess  was  located  in  the  left  lobe  of  the  liver.  This 
patient  was  operated  upon  by  abdominal  section,  and  the  oper- 
ation was  completed  in  one  sitting.  This  is  the  invariable  rule 
followed  by  Dr.  Wildt.  The  peritoneal  cavity  is  protected 
against  contamination  during  the  operation  and  drainage  by  a 
gauze  pack  as  long  as  is  required.  The  same  rule  is  followed 
when  the  abscess  has  to  be  opened  through  the  free  pleural 
cavity.  Dr.  Wildt  does  not  fear  pulmonary  collapse  and  only 
in  one  out  of  more  than  300  cases  was  the  operation  the  cause  of 
a  subsequent  empyema.  Dr.  Wildt  has  up  to  the  present  time 
operated  upon  340  cases  of  abscess  of  the  liver,  with  the  follow- 
ing results :  Mortality  of  the  first  hundred  cases,  38%  ;  the 
second  hundred,  32%  :  the  third  hundred,  20%.  The  statistics 
prove  that  like  in  any  other  important  operations  the  results 
improve  with  increasing  experience. 


streptococcus  Infect  ion.— The  streptococcus  is  almost  ubiqui- 
tous, but  there  are  places  in  which  this  microbe  is  rare  or 
entirely  absent.  It  is  said  by  Professor  Bitter  and  others  in 
Cairo  that  the  most  careful  bacteriologic  investigations  have 
shoAvn  that  it  is  almost  entirely  absent  in  Khartoum,  Egypt. 
In  the  valley  of  the  Nile  this  pus  microbe  appears  to  be  very 
common.  Many  patients  with  furunculosis  come  to  the  clinics 
and  into  the  hospitals.  This  affection  is  here  called  the  Nile 
pustule.  It  appears  in  the  form  of  a  multiple  suppurative  affec- 
tion of  the  sweat  glands.  It  attack  s  most  frequently  the  exposed 
cutaneous  surfaces — the  face,  neck,  hands  and  forearms.  The 
exciting  cause  in  most  instances  is  the  streptococcus.  Multiple 
large  abscesses  are  also  frequently  met,  and  in  many  instances 
it  is  impossible  to  find  a  peripheral,  recognizable  infection- 
atrium.  I  found  two  such  cases  in  the  Victoria  Hospital  under 
the  care  of  Dr.  Wildt.  These  abscesses  are  not  without  danger 
to  life,  particularly  in  patients  suffering  from  anemia  or  some 
other  antecedent  debilitating  disease. 

Cairo,  July  5. 


[Rejuinted  from  American  Medicine,  Vol.  IV,  No.  15,  pages  587-589, 
October  II,  1902.  | 


PROFESSOR  NICOLADONI'S  CLINIC,  GRATZ. 

BY 

NICHOLAS  SEXN,  M.D., 
of  Chicago. 

Gratz  is  a  charming  university  city,  with  a  happy,  contented, 
peaceful,  refined  population  of  120,000. 

The  little  city  is  beautifully  located  in  a  green,  fertile 
valley,  surrounded  by  lorest-olad  mountains  and  bisected  by  a 
tumultuous  tearing  stream  of  the  purest,  crystal-clear  water. 
Although  the  city  is  in  the  direct  line  of  railway  travel  from 
Trieste  to  Vienna,  it  is  not  much  frequented  by  tourists,  and 
the  advantages  offered  by  its  university  have  not  been  suffi- 
ciently appreciated  by  those  who  seek  postgraduate  education 
abroad.  The  University  of  Gratz  recently  celebrated  its  third 
centennial.  The  medical  department  was  organized  35  years 
ago,  and  has  no  w  an  attendance  of  300  students.  The  laboratory 
facilities  are  excellent,  and  the  clinical  material  far  beyond 
requirements.  The  surgical  clinic  has  280  beds,  and  receives 
much  valuable  material  from  the  outdoor  department.  The 
operating  amphitheater  has  all  modern  improvements,  instru- 
ments and  appliances,  is  well  lighted  and  can  seat  from  85  to  100 
students. 

Professor  Nicoladoni,  formerly  of  Innsbruck,  came  here  in 
1893  to  take  the  chair  of  surgery  made  vacant  by  the  resignation 
of  Professor  Wolffier,  who  accepted  a  call  from  Prague.  Nico- 
ladoni is  a  modest,  hardworking,  scientific  surgeon,  and  an 
impressive  teacher.  His  book  on  scoliosis,  which  was  pub- 
lished about  the  time  he  left  Innsbruck,  is  a  masterpiece  of 
careful  investigation  and  sound  teaching,  and  is  now  being 
revised  by  its  distinguished  author,  and  will  soon  make  its 
appearance  much  enlarged  and  more  fully  illustrated.  His 
contributions  to  surgical  literature  have  been  many,  and  all  of 
them  are  noted  for  the  originality  of  the  material  they  contain. 
His  fame  as  a  plastic  surgeon  has  given  him  an  international 
reputation.  He  was  the  first  surgeon  to  practise  tendoplasty,  a 
branch  of  orthopedic  surgery  which  has  since  been  so  rapidly 
developed  and  practised  on  such  a  large  scale  by  Hoffa  and 
others.  His  most  recent  innovation  in  plastic  work  is  the  use 
of  cartilage  taken  from  the  ribs  out  of  which  to  make  an  unyield- 
ing framework  for  the  frontal  flap  in  rhinoplasty.  This  opera- 
tion will  be  fully  described  further  on.     In  his  clinic  he  is 


assisted  by  four  resident  surgeons.  The  work  begins  each  day 
at  9.30  a.m.,  and  it  is  seldom  finished  before  2  p.m.  During 
this  time  two  and  sometimes  three  operate  simultaneously. 
His  first  assistant,  Dr.  Payr,  received  an  assistant  professor- 
ship a  few  days  ago,  and  the  event  was  appropriately  cele- 
brated. Professor  Payr,  although  a  young  man,  has  reached 
well  merited  distinction  by  his  original  work  on  the  use  of 
magnesium  in  surgery.  In  Xicoladoni's  clinic,  choloroform 
and  the  A.  C-  E.  mixture  are  used  as  anesthetics.  Silk  has 
almost  entirely  taken  the  place  of  catgut.  Gloves  have  been 
abandoned.  Hand  disinfection  consists  of  thorough  scrubbing 
with  water  and  marble  soap,  followed  by  alcohol  and  subli- 


Arrows  of  magnesium  in  cavernous  venous  angioma. 

mate  solution.    Recent  wounds,  when  no  drainage  is  required, 
are  covered  with  Bruns'  airol  paste.    This  paste  consists  of 

B^lSl  alb.  I  «^  each 20 

Glycerin ss. 


The  yellow  paste  becomes  firm  in  a  short  time  and  is  easily 
washed  away  with  warm  water.  It  is  claimed  that  this  paste  is 
one  of  the  means  to  prevent  stitch  abscesses. 

Magnesium  in  Surgery.— Dr.  Payr  has  made  the  effects  of 
magnesium    on   the   tissues  a  special    study  for  a  long  time. 


3 


Pieces  of  this  metal  introduced  into  the  living  tissues  produce 
certain  definite  chemic  changes  which  effect  the  absorption  of 
the  metal.  Under  its  action  the  watery  constituents  of  the  tis- 
sues are  reduced  to  the  original  elements,  oxygen  and  hydro- 
gen. The  gases  evolved  accumulate  around  the  metal,  the 
oxygen  combines  with  it  and  forms  a  soluble  magnesium  oxid. 
The  hydrogen  is  absorbed.  Payr  has  found  the  magnesium 
wire  too  brittle  for  suture  and  ligature  material.  He  has  used 
nails  made  of  this  material  for  direct  fixation  of  fractures  and 
in  immobilizing  the  bone  ends  after  resection.  Nails  of  the 
thickness  of  a  small  lead  pencil  are  absorbed  in  the  course  of 
three  to  four  weeks.  He  has  made  many  experiments  with  a 
small  grooved  magnesium  ring  in  vmiting  severed  blood  vessels. 
In  uniting  a  severed  artery  the  ring  is  slipped  over  the  proximal 


3. 


A,  B,  C,  application  of  magnesium  ring.    D,  Payr's  magnesium  ring 
for  uniting  severed  bloodvessels. 

end  and  after  turning  the  coats  of  the  artery  back  and  over  it  a 
ligature  is  applied  over  the  groove  of  the  ring.  (See  illustra- 
tion.) With  four  fine  silk  sutures  the  distal  end  is  drawn  over 
the  proximal  end,  thus  bringing  intima  in  contact  with  intima 
over  a  considerable  surface,  when  a  second  ligature  is  applied 
to  maintain  the  invagination.  The  continuity  of  the  artery  is 
restored  in  this  manner  by  means  of  the  extra  vascular  magne- 
sium ring  and  two  fine  silk  ligatures.  The  ring  is  absorbed  in 
three  weeks,  and  the  vessel  unites  as  a  rule  without  the  forma- 
tion of  a  thrombus.  In  uniting  a  severed  vein  the  ring  is 
applied  to  the  distal  end,  as  the  invagination  must  be  made  in 
the  direction  of  the  blood  current.  He  has  resorted  to  this  pro- 
cedure with    success    in  the  case  of  a  wound  of  the  common 


femoral  vein  inflicted  accidentally  during  an  operation  for  the 
removal  of  carcinomatous  glands  in  Scarpa's  triangle.  Four 
centimeters  of  the  vein  were  resected,  the  ends  united  in  the 
manner  described.  The  patient  died  three  days  later  and  the 
postmortem  established  the  fact  that  the  union  was  firm  and 
the  lumen  of  the  vein  free  from  thrombus  formation.  Nicola- 
doni  also  suggested  the  use  of  magnesium  in  the  case  of  a  large 
venous  angioma  of  the  face.  At  different  times  needle-like 
fragments  of  the  metal  were  inserted  into  the  tumor  through 
punctures  made  with  a  tenotome.  At  the  time  of  my  visit  about 
22  magnesium  arrows  had  been  inserted  and  at  different  points 
gaseous  crepitation  could  be  elicited  around  the  foreign  sub- 
stances on  pressure.  The  tumor  had  diminished  under  this  treat- 
ment more  than  one-half  its  size.  This  new  therapeutic  agent 
is  entitled  to  a  fair  trial  in  the  management  of  cavernous  venous 
angioma  not  adapted  for  a  more  speedy  treatment  by  excision. 

Clinical  Cases. — The  following  are  some  of  the  more  im- 
portant operations  that  came  under  my  observation  during  my 
two  visits  to  Nicoladoni's  clinic  : 


Case  1.— Rhinoplasty  by  NicoladonVs  method.    The  patient 
was  a  man  about  30  years  of  age.    Nearly  the  entire  nose  had 

been  de5<troyed  by 
syphilitic  'ulcera- 
tion. There  were 
numerous  facial 
scar  s  from  the 
same  cause.  Two 
months  ago  the 
first  operation  was 
performed.  A 
number  of  ribs 
were  exposed  by 
an  incision  over  the 
costal  arch  on  the 
right  side.  With  a 
resection  knife  a 
piece  of  cartilage 
about  four  inches 
in  length  was  ex- 
cised from  the  bor- 
der of  one  of  the 
ribs.  This  piece 
was  intended  to 
serve  as  a  support 
for  the  bridge  of 
the  new  nose  and 
the  septum  ;  it  was 
implanted  oblique- 
ly underneath  the 
skin  between  it  and 
the  occipitofron- 
talis  on  the  left  side 
of  the  median  line  of  the  forehead.  A  number  of  fragments  of 
cartilage  were  inserted  at  right  angles  on  each  side  so  that  the 


Nicoladoni's  case  of  rhinoplasty,  showing  the 
subcutaneous  Maltese  cross  of  cartilage  be- 
fore second  operation. 


subcutaneous  cartilaginous  framework  represented  somewhat 
in  outline  a  Maltese  cross.  The  crossbars  were  intended  to 
serve  as  supports  for  the  al?e  of  the  new  nose.  The  implanted 
cartilages  could  be  distinctly  seen  and  felt  underneath  the  skin, 
and  their  position  and  prominence  are  well  shown  in  the 
accompanying  photograph.  A  guttapercha  model  of  the  nose 
was  made,  and  over  this  the  paper  was  cut  with  which  to  out- 
line the  frontal  flap.  Under  strict  aseptic  precautions  the 
rhinoplasty  was  made.  The  flap  included  all  of  the  tissues 
down  to  the  frontal  bone.  The  free  margins  of  the  alse  and  the 
septum*  were  lined  by  turning  the  skin  in  the  direction  of  the 
nasal  cavities  and  suturing  it  with  fine  silk.  The  immediate 
cosmetic  resultwas  excellent.  The  frontal  defect  was  reduced 
in  size  by  tension  sutures,  and  will  be  paved  with  Thiersch's 
skin  grafts  as  soon  as  the  surface  is  covered  with  granulations. 
The  nasal  cavities  were  not  packed  with  gauze.  An  external 
absorbent  dressing  completed  the  operation. 

This  case  will  unquestionably  prove  a  great  success,  and 
will  be  reported  in  full  by  the  operator  so  soon  as  the  remote 
cosmetic  result  can  be  determined. 

Case  II.  —  Strumectomy  for  2)^i'>^6nchymatous  struma. 
Operation  performed  by  Prof.  Payr :  The  patient,  a  girl,  aged 
20,  was  the  subject  of  a  symmetric  struma  which  recently  had 
commenced  to  give  rise  to  pressure  symptoms.  The  swelling 
is  smooth,  of  uniform  consistency,  and  descends  somewhat 
behind  the  jugulum  of  the  sternum.  Patient  otherwise  is  in 
excellent  health.  Chloroform  was  used  as  an  anesthetic.  The 
operation  was  performed  with  the  patient  nearly  in  a  sitting 
position.  Kocher's  anterior  curved  incision  was  made  down  to 
the  capsule  of  the  swelling  and  hemorrhage  carefully  arrested 
as  the  operation  proceeded.  Some  of  the  larger  veins  were  cut 
between  a  double  ligature.  The  left  lobe  was  first  removed. 
The  thyroid  arteries  and  veins  were  ligated  separately.  The 
isthmus  of  the  gland  was  isolated  and  a  vertical  linear  crush- 
ing was  made  with  a  pair  of  crushing  forceps,  and  ligated  with 
a  silk  and  a  strong  catgut  ligature  when  the  left  lobe  was 
removed.  On  the  right  side  only  the  superior  thyroid  artery 
and  vein  were  ligated  and  only  a  portion  of  the  lobe  excised 
after  preliminary  en  masse  ligations  with  catgut,  as  advised  by 
Mikulicz.  The  operation  was  completed  in  less  than  an  hour 
and  with  the  loss  of  not  more  than  a  teaspoonful  of  blood.  The 
clean  anatomic  dissection  and  the  careful  hemostasis  exhibited 
the  work  of  a  master. 

Struma  is  very  prevalent  in  the  mountainous  regions  of 
Austria.  In  the  Gratz  surgical  clinic  about  75  strumectomies 
are  performed  annually. 

Case  III. — Abdominal  tumor ;  death  from  the  anesthetic. 
The  patient,  a  multipara,  about  35  years  of  age,  was  admitted 
into  the  clinic  a  few  days  ago  suffering  from  an  abdominal 
tumor.  The  patient's  mental  faculties  were  much  impaired 
and  her  statements  concerning  the  early  history  of  the  growth 
could  not  be  depended  upon.  Emaciation  was  marked  as  well 
as  the  anemia.  The  tumor,  the  size  of  a  child's  head,  occupied 
the  right  iliac  fossa.  It  was  hard,  nodulated  and  not  freely 
movable.  For  some  time  she  had  had  symptoms  of  intestinal 
obstruction  without  vomiting.    The  abdomen  was  tympanitic, 


the  muscles,  however,  were  relaxed.  Xo  temperature  or  any- 
other  signs  of  peritonitis.  Tuberculosis  or  malignant  disease 
of  the  cecum  was  suspected.  From  the  general  appearance  of 
the  patient  it  was  evident  that  the  case  was  almost  a  hopeless 
one.  The  A.  C.  E.  was  cautiously  administered,  the  field  of 
operation  prepared  and  the  surgeon  was  in  the  act  of  making 
the  first  incision  when  respiration  and  the  heart's  action  ceased 
almost  simultaneously.  Artificial  respiration  was  performed, 
camphoi -ether  injected  subcutaneously,  but  no  response  fol- 
lowed. These  fruitless  efforts  were  continued  for  half  an  hour 
when  the  corpse  was  sent  to  the  morgue  for  a  legal  autopsy. 

Case  IV. — Carcinoma  of  the  'mamma;  excision.  The  patient 
was  a  woman,  somewhat  advanced  in  years,  who  was  at  the 
same  time  the  subject  of  a  large  goiter,  which,  however,  caused 
no  inconvenience.  Under  chloroform  anesthesia  the  entire 
breast  with  overlying  skin  and  underlying  pectoralis  major 
were  removed  first,  when  the  axilla  was  cleared  out.  The  lower 
part  of  the  wound  could  not  be  closed  and  was  left  open  to  heal 
by  granulation.  Tubular  drainage  for  the  axillary  space  was 
instituted  and  a  large  absorbent  dressing  applied. 

Case  V. — Right  inguinal  hei^tiia ;  radical  operation  by  Bas- 
sini's  method.  The  hernia  was  a  small  one  and  a  straight 
incision  was  made  over  the  inguinal  canal.  Sac  and  spermatic 
cord  and  vessels  were  isolated  and  drawn  forward  with  a  strip 
of  iodoform  gauze  placed  underneath  them.  Isolation  of  sac, 
which  was  excised  below  the  silk  ligature  applied  to  its  neck. 
Closure  of  canal  by  Bassini's  method.  The  wound  was  sealed 
with  Bruns'  paste,  over  which  a  compress  of  cotton  was 
applied  and  held  in  place  by  a  spica  bandage. 

Hernia  operations  are  performed  in  this  clinic  daily  and 
inguinal  hernias  always  by  Bassini's  method.  The  patients  are 
permitted  to  leave  bed  in  10  to  14  days. 

In  1,500  patients  operated  upon,  recurrence  is  said  to  have 
followed  only  in  2%,  certainly  a  result  it  Avould  not  be  easy  to 
duplicate. 

Case  Y1.— Relapsing  appendicitis  laparotomy;  appendix 
not  found.  The  patient,  a  young  man,  had  his  first  and  severest 
attack  four  years  ago,  followed  by  mild  attacks  nearly  every 
month  since.  No  palpable  swelling  in  the  ileocecal  region.  In 
making  the  abdominal  incision  in  the  customary  place  and 
direction  all  of  the  layers  were  divided.  A  piece  of  the  great 
omentum  adherent  over  the  cecum  was  divided  between  two 
silk  ligatures.  Search  was  now  made  for  the  appendix.  The 
posterior  surface  of  the  cecum  was  found  firmly  attached  to  the 
iliac  fossa.  The  adhesions  were  separated  with  the  greatest  care. 
An  enlarged  mesenteric  gland  embedded  in  the  adhesions  and 
first  mistaken  for  the  appendix  was  removed.  The  operator 
with  the  utmost  patience  and  care  continued  the  search  for 
nearly  two  hours,  when  the  space  made  behind  the  cecum 
caused  by  separating  the  adhesions  was  drained  with  a  long 
strip  of  iodoform  gauze  and  the  incision,  at  least  six  inches  in 
length,  was  closed  with  four  rows  of  silk  sutures. 

This  was  evidently  one  of  those  trying  cases  in  which  dur- 
ing the  first  attack  a  large  retrocecal  abscess  ruptured  into  the 
cecum  after  partial  or  complete  sloughing  of  the  appendix. 


Gxi>,TS,Yll.—Scrotal  hernia  of  large  size;  radical  operation 
by  Ba.ssinPs  method.  This  was  a  good  test  case  for  Bassini's 
operation.  The  hernia  was  the  size  of  a  cocoanut  and  the  open- 
ing in  the  aVjdominal  wall  large  enough  to  admit  three  fingers. 
The  patient  was  a  young  man  otherwise  in  perfect  health.  The 
hernia  was  located  on  the  right  side  and  had  existed  for  a  num- 
ber of  years.  No  attempt  had  been  made  to  retain  it  by  truss 
pressure.  The  incision  was  made  over  the  center  of  the  swell- 
ing and  in  the  direction  of  the  shortened  inguinal  canal.  The 
sac  contained  the  cecum  and  several  loops  of  the  small  intes- 
tines. The  separation  of  the  sac  required  much  time  and 
patience.  In  the  isolation  of  the  sac  the  operator  made  frequent 
use  of  short  chopping  strokes  with  a  short-bladed  scalpel.  The 
sac  was  ligated  and  excis^ed  in  the  usual  manner.  Six  silk 
sutures  were  necessary  to  close  the  inguinal  canal  underneath 
the  cord  and  its  vessels.  The  deep  fascia  was  sutured  over  the 
cord  with  very  tine  silk  sutures  and  the  skin  united  in  a  sim- 
ilar manner.  The  wound  was  sealed  with  Bruns'  paste,  over 
which  a  cotton  compress  was  applied. 

Case  VIII. — Faficia  sarcoma  in  right  parotid  region ;  exci- 
sion. The  patient  was  a  woman,  aged  35.  A  swelling  over  the 
lower  segment  of  the  right  parotid  gland  was  noticed  first  a 
few  months  ago.  The  growth  was  rather  rapid  and  compara- 
tively painless.  The  tumor  was  the  size  of  a  walnut,  movable, 
and  the  skin  over  it  was  normal.  Skin  was  incised  vertically 
and  the  tumor  removed  with  a  zone  of  apparently  healthy  tis- 
sue. The  cut  surface  of  the  tumor  on  section  presented  all  of 
the  macroscopic  appearances  of  a  fascia  sarcoma.  The  capsule 
of  the  parotid  gland  was  intact.  Wound  was  sutured  and 
sealed  with  Bruns'  paste. 

Case  IX. — Tuberculosis  of  lymphatic  glands  within  the  cap- 
sule of  the  parotid ;  removal  of  tuberculous  prodiict  with  sharp 
spoon.  The  patient  was  a  young  anemic  woman.  Development 
of  the  swelling,  which  was  the  size  of  a  pigeon's  egg,  was  slow 
and  without  much  discomfort.  Under  chloroform  anesthesia 
the  swelling  was  incised  and  cheesy  material  scraped  out  with 
a  sharp  spoon.  The  wound  was  sutured  and  sealed  with  Bruns' 
paste. 

Case  ^.—Recurring  tuberculosis  of  glands  of  right  side  of 
neck ;  excision  of  affected  glands.  The  patient,  a  young  anemic 
woman,  was  operated  upon  a  few  months  ago  for  the  same 
affection.  A  clean  excision  was  made  of  all  affected  glands  and 
fistulous  tracts.  Partial  suturing  of.wound  was  done  and  iodo- 
form gauze  drainage  instituted. 

Case  ^l.— Femoral  hernia ;  radical  operation.  The  patient, 
a  woman,  aged  50,  had  a  hernia,  size  of  hen's  egg,  on  her  right 
side.  Swelling  disappears  in  the  recumbent  position.  Verti- 
cal incision,  four  inches  in  length,  was  made  over  the  crural 
canal.  Excision  of  sac  was  followed  by  suturing  of  Poupart's 
ligament  to  the  periosteum  of  the  pubes  with  four  silk  sutures. 
External  wound  Avas  sutured  and  sealed  with  Bruns'  paste. 

Case  XII. — Lipoma  over  upper  part  of  right  biceps  muscle ; 
operation  under  local  anesthesia  by  iSehleich^s  infiltration 
method.  The  patient  was  an  elderly  woman  who  had  a  flat, 
lobulated,  movable,  subcutaneous  tumor  the  size  of  a  woman's 
fist,  below  the  shoulder-joint.  Schleich's  solution  was  injected 
into  the  skin  in  the  line  of  the  purposed  incision.  The  incision 
was  made  without  causing  much  pain.  The  loose  connective 
tissue  around  the  tumor  was  then  infiltrated,  but  during  the 


enucleations  the  patient  evinced  pain.  The  wound  was  sutured 
and  sealed  with  Bruus'  paste. 

The  above  cases  shoAv  what  is  being  done  daily  in  the  Gratz 
surgical  clinic.  Professor  Nicoladoni  has  a  splendid  staff  of 
assistants  who  lighten  the  arduous  work  of  their  chief  as  much 
as  is  within  their  power.  They  perform  nearly  all  of  the  minor 
operations  and  do  not  shrink  from  the  most  difficult  task  when 
the  professor  makes  the  request.  Nicoladoni  stimulates  his 
assistants  by  example  and  suggestion  to  original  research,  a 
fact  which  accounts  for  the  many  valuable  reports  and  scien- 
tific papers  which  are  credited  to  his  clinic  by  his  enthusiastic 
and  devoted  assistants. 
Geatz,  July  11. 


[Reprinted  from  American  Medicine,  Vol.  IV,  No.  16,  pages  627-629, 
October  18,  1902.] 


THE  TEACHING   AND   PRACTICE   OF  SURGERY  IN 
THE  VIENNA  ALLGEMEINE  KRANKENHAUS. 

BY 

NICHOLAS  SENN,  M.D., 
of  Chicago. 

The  Vienna  Allgemeine  Krankenhaus  is  a  little  city  in  itself 
with  a  population  of  more  than  3,000  inhabitants.  Its  present 
capacity  is  2.600  beds.  The  obstetric  department,  with  600  beds, 
has  been  transferred  to  another  locality,  but  is  under  the  same 
management.  This  hospital  is  to  the  sick  poor  of  Vienna  what 
the  Charite  is  to  Berlin,  only  it  is  much  larger.  The  original  hos- 
pital was  built  in  1784.  The  buildings  have  been  repeatedly 
repaired  and  improved  and  new  additions  have  been  made  as 
the  increasing  demand  for  more  space  required.  The  old  build- 
ings are  in  good  condition,  and  with  their  new  mosaic  floors 
present  a  modern  appearance.  The  wooden  bedsteads  and 
feather  beds  have  disappeared,  and  have  been  replaced  by  iron 
cots  with  spring  mattresses,  snow  white  linen  and  comfortable 
quilts  and  blankets.  The  wax  candles  are  only  seen  in  the 
chapel,  as  all  the  wards,  operating-rooms  and  living-rooms  are 
brilliantly  illuminated  by  electricity.  Many  of  the  recent 
improvements  are  the  creation  of  the  present  Director  Ober- 
sanitalsrath,  Dr.  Victor  Mucha.  The  institution  has  been 
under  his  management  for  eight  years,  and  during  that  time 
many  useful  changes  have  been  made.  Dr.  Mucha  is  a  man  of 
profound  learning,  unlimited  enthusiasm,  and  an  ideal  dis- 
ciplinarian. He  works  in  harmony  with  the  medical  staff,  and 
is  respected  and  loved  by  all  the  inmates  of  the  institution. 
He  is  ably  supported  in  his  arduous  duties  by  his  assistant, 
Dr.  Knodl.  Dr.  Mucha  takes  a  just  pride  in  the  new  steriliza- 
tion plant  for  surgical  dressings  which  has  been  in  successful 
operation  for  four  years.  This  was  the  outcome  of  a  careful 
personal  inspection  and  study  of  the  different  processes  of 
sterilization  in  all  of  the  principal  hospitals  of  Europe.  It  is 
the  finest  and  most  complete  sterilization  plant  in  the  world. 
The  room  adjoins  the  dispensary,  and  is  under  the  direction  of 
the  chief  druggist,  Adjunct  Gmeut.  An  automatic  clockwork 
connects  the  two  rooms  and  gives  the  f^ignals  for  the  functions 
of  the  Adjunct  with  an  unfailing  precision.  Oversteam  effects 
the  sterilization  and  dry  heat  dries  the  dressings.    All  of  the 


sterilized  dressings  are  subjected  to  bacteriologic  tests  and  a  care- 
ful record  is  kept  of  the  results  of  the  sterilization.  The  dressings 
for  each  of  the  13  surgical  stations  are  placed  in  a  metallic  cylinder 
and  after  sterilization  the  cylinder  is  locked  and  a  stamp  bear- 
ing the  date  of  sterilization  is  placed  over  the  keyhole.  The 
only  two  persons  who  hold  the  keys,  the  chief  druggist  and  the 
nurse  in  the  operating-room,  are  the  only  persons  responsible 
for  the  ascepticity  of  the  dressings.  The  chief  druggist  is  now 
engaged  in  a  series  of  experiments  calculated  to  solve  the  prob- 
lem of  speedy  and  effective  sterilization  of  silk.  The  M'ork  in 
the  Rontgen  room  is  done  by  an  expert.  Dr.  Oppenheim.  Sev- 
eral hours  spent  in  this  department  will  reveal  all  of  the  won- 
derful results  of  the  present  status  of  the  diagnostic  and  thera- 
peutic value  of  the  Rontgen  ray.  The  Allgemeine  Kranken- 
haus  has  been  the  central  figure  of  the  progress  in  medicine 
and  surgery  during  the  last  six  decades.  During  all  this  time 
it  has  been  the  great  center  for  the  diffusion  of  the  knowledge  of 
modern  pathology.  It  has  been  and  is  now  the  mecca  for 
students  from  all  parts  of  the  world  who  are  in  search  of  the 
basis  of  rational  medicine— a  thorough  knowledge  of  gross  and 
microscopic  pathology.  The  great  morgue  of  this  hospital  was 
the  workshop  in  which  Rokitansky  made  his  international 
reputation.  Here  gross  and  microscopic  morbid  anatomy  are 
taught  today  more  thoroughly  than  in  any  other  institution  in 
the  world.  Here  the  student  can  see  from  10  to  25  autopsies 
every  day,  and  here  every  pathologic  lesion  is  subjected  to  a 
most  painstaking  microscopic  examination.  The  next  thing 
w^hich  attracts  the  attention  of  students  from  foreign  lands  in 
this  institution  is  clinical  diagnosis.  Bamberger  made  this 
branch  of  scientific  medicine  famous  and  Nothnagel  and 
Kowacs  are  now  the  men  whose  teachings  are  eagerly  sought. 
It  was  in  this  institution  that  the  immortal  Billroth  reached 
the  climax  of  his  unparalleled  reputation  as  a  surgeon.  It  was 
the  material  from  the  postmortem-room  of  this,  the  greatest 
hospital  in  the  world,  that  Kyrtl  drew  his  inspiration  and 
became  the  greatest  anatomist  the  world  ever  knew.  This  ven- 
erable institution  remains  a  source  of  incalculable  benefit  to 
the  profession  at  large  and  will  continue  to  remain  so  for  cen- 
turies to  come. 

Billroth  made  it  the  great  school  for  modern  surgery. 
Many  of  his  pupils  and  assistants  have  become  distinguished 
authors  and  famous  teachers.  Two  of  them  now  occupy  the 
two  chairs  of  surgery  in  the  University.  Vienna  has  not  forgot- 
ten the  epoch-making  teachings  of  her  Billroth.  One  of  the 
great  thoroughfares  of  the  city  is  now  known  as  the  "  Billroth 
Arcade,"  and  a  handsome  bust  of  the  profound  scholar,  the 
prolific  author,  and  the  original  surgeon,  ornaments  one  of  the 


University  halls.  The  number  of  students  attending  the 
University  has  greatly  diminished  since  the  demise  of  its 
three  greatest  lights— Rokitansky,  Kyrtl,  and  Billroth.  At 
present  it  does  not  exceed  1,500.  The  time  limit  for  graduation 
is  five  years  and  about  200  are  graduated  annually. 

Nursing  Force.— One  of  the  apparent  great  defects  of  this 
hospital  is  the  lack  of  well-trained  female  nurses.  Ninety 
Catholic  Sisters  serve  in  the  capacity  of  nurses,  but  none  of  them 
have  had  the  necessary  theoretic  and  practical  training.  The 
same  can  be  said  of  the  orderlies  and  male  nurses.  I  was 
informed  that  in  the  near  future  a  training  school  under  the 
direction  of  Professor  von  Mosetig-Moorhof  will  be  established, 
and  it  is  to  be  hoped  that  this  project  will  soon  be  realized,  as 
it  would  meet  one  of  the  most  urgent  demands  of  this,  the 
greatest  refuge  for  the  sick. 

Professor  Freiherr  von  Eiselsherq'' s  Clinic.  —  Professor 
Eiselsberg  succeeded  Professor  Albrecht  as  the  chief  of  the 
first  surgical  clinic.  He  was  one  of  Billroth's  most  talented 
and  favorite  students  and  taught  surgery  in  a  subordinate  posi- 
tion for  several  years  in  Vienna,  when  he  was  called  to  Holland 
and  later  to  Konigsberg,  Germany,  as  professor  of  surgery.  He 
has  not  passed  beyond  the  meridian  of  life  and  has  already 
attained  an  enviable  reputation  as  an  investigator  and  surgeon. 
His  present  exalted  position  marks  the  climax  of  his  academic 
career.  His  ambition  has  been  gratified  and  he  has  now  an 
opportunity  to  use  his  talents  in  one  of  the  most  cosmopolitan 
clinics  in  the  world.  He  is  well  prepared  for  the  task  before 
him.  He  is  a  fluent  speaker  and  an  expert  operator.  He  takes 
great  delight  in  performing  difficult  operations.  He  is  an 
enthusiast  in  his  profession  and  has  the  faculty  of  imparting 
this  desirable  quality  of  a  surgeon  to  his  hearers.  In  his  clin- 
ical lectures  he  devotes  most  of  his  time  to  the  scientific  part  of 
surgery,  surgical  anatomy,  pathology  and  diagnosis.  All  of  his 
major  operations  are  performed  in  a  small  room,  to  which  stu- 
dents and  practitioners  have  access  in  small  sections.  Those 
who  attend  his  operations  must  appear  in  linen  coats  and 
rubber  shoes.  The  aseptic  details  are  very  exacting.  The 
operator  and  his  assistants  each  wear  cotton  gloves,  a  white  cap 
and  a  gauze  mask  for  the  face.  This  mask  is  an  ordinary 
Esmarch  inhaler,  to  which  a  spectacle  framework  is  attached. 
To  what  extent  such  a  mask  can  contribute  to  aseptic  precau- 
tions will  be  determined  only  in  a  very  few  clinics.  The  A.  C. 
E.  mixture  is  the  anesthetic  used.  Hand  disinfection  consists 
in  scrubbing  with  warm  flowing  water  and  potash  soap  for  five 
minutes,  followed  by  alcohol  and  sublimate.  The  field  of  opera- 
tion is  disinfected  in  a  similar  manner  after  the  patient  is  under 
the  influence  of  the  anesthetic.    Silk  is  the  material  used  for 


ligatures  and  sutures.    During  tlie  clinic  I  attended  the  follow- 
ing operations  were  performed : 

Case  I. — Large  hronchocele ;  strumectomy.  The  patient 
was  a  country  woman,  aged  51.  The  tliyroid  gland  commenced 
to  enlarge  20  years  ago,  and  for  several  years  the  swelling  has 
prod  viced  pressure  symptoms  at  irregulaV  intervals.  The  entire 
gland  is  involved,  but  the  right  lobe  is  much  larger  than  the 
left.  The  swelling  is  nodular  and  firm,  and  the  right  lobe  Avith 
a  part  of  the  isthmus  is  in  part  retrosternal.  It  is  this  part  of 
the  swelling  that  is  responsible  for  the  temporary  attacks  of 
embarrassment  of  respiration.  Although  Eiselsberg  prefers 
to  perform  strumectomy  under  local  anesthesia,  an  exception 
was  made  in  this  case  at  the  urgent  request  of  the  patient  and 
the  A.  C,  E  mixture  was  administered.  The  anesthesia  at  no 
time  gave  rise  to  any  serious  or  even  unpleasant  symptoms. 
The  head  and  chest  were  placed  in  a  slightly  elevated  position, 
and  the  neck  rested  in  extended  position  upon  a  circular  pillow. 
A  curved  incision  with  the  curve  extending  outward  was  made 
over  the  right  lobe  of  the  swelling.  Vv^ith  quick  strokes  of  the 
knife  the  capsule  of  the  tumor  was  reached  and  hemorrhage 
arrested  by  the  use  of  many  hemostatic  forceps.  All  of  the 
bleeding  points  were  then  tied  with  fine  silk  ligatures.  A  por- 
tion of  the  tumor  the  size  of  a  walnut  at  a  point  where  the 
superior  thyroid  artery  enters  the  gland  was  tied  off  with  cat- 
gut ligatures  and  severed  with  the  knife.  The  retrosternal  part 
of  the  tumor  was  next  liberated  by  blunt  dissection.  The 
inferior  thyroid  vessels  were  divided  between  two  ligatures. 
In  separating  the  tumor  from  the  trachea  all  of  the  visible 
vessels  were  tied  and  cut  in  a  similar  manner.  The  isthmus  of 
the  gland  was  subjected  to  vertical  linear  crushing  before  the 
ligatures  were  applied,  when  the  mass,  as  large  as  a  man's  fist, 
was  amputated.  The  trachea  w'as  found  considerably  flattened. 
The  left  lobe  was  not  removed.  A  strip  of  nosopheu  gauze 
was  used  to  establish  capillary  drainage,  and  the  balance 
of  the  wound  was  closed  with  silk  sutures  and  the  usual  aseptic 
absorbent  dressing  applied.  Cystic  and  calcareous  degenera- 
tion marked  the  location  of  the  multiple  adenomas  imbedded  in 
the  miasmatic  struma. 

Case  II. — Sfruriia  complicated  by  echinococcus  cyst:  incision 
and  drainage.  The  patient,  a  woman,  aged  45,  had  been  the 
subject  of  an  enlargement  of  the  thyroid  gland  since  girlhood. 
The  swelling  caused  no  inconvenience  until  a  number  of 
months  ago,  when  it  suddenly  increased  in  size,  became  painful 
and  tender.  Supyjuration  ensued,  and  w^hen  the  large  abscess 
was  incised  a  large  quantity  of  fetid  pus  escaped.  The  acute 
symptoms  subsided  but  the  abscess  never  healed.  A  fistulous 
opening  near  the  sternoclavicular  joint  leads  into  the  large 
goiter  toward  the  right  side  where  the  swelling  is  most  promi- 
nent. This  sudden  attack  was  taken  for  an  acute  suppurative 
strumitis  and  it  was  the  intention  of  the  operator  to  remove  the 
right  lobe  of  the  gland  with  the  abscess  cavity.  The  operation 
"was  performed  under  local  anesthesia.  The  external  incision 
was  made  in  the  same  manner  as  in  Case  I.  After  the  swelling 
was  exposed  by  reflection  of  the  semilunar  skinflap,  the  fistula 
was  followed  into  a  cavity  the  size  of  a  small  cocoanut  which 
contained  a  teacupful  of  the  broken-down  products  of  an  echi- 
nococcus cyst.  The  anterior  wall  of  this  cavity  was  excised,  the 
floor  thoroughly  scraped  out  with  a  sharp  spoon  and  in  several 
places  the  surface  was  cauterized  with  the  Paquelin  cautery. 


The  cavity  was  then  packed  with  a  long  strip  of  nosophen 
gauze  and  the  incision  sutured  down  to  the  drainage  opening. 
This  case  is  an  extremely  rare  one.  The  echinococcus  cyst 
developed  in  the  interior  of  a  parenchymatous  struma  and  the 
suppuration  which  ensued  in  its  interior  simulated  in  every 
respect  a  suppurative  strumitis  as  described  by  Tavel  and 
others.  It  was  the  echinococcus  part  of  the  swelling  which 
caused  the  distressing  clinical  symptoms  and  the  elimination 
of  this  unusual  complication  by  operative  interference  will  be 
followed  by  permanent  relief. 

Case  111.— Cicatricial  stenosis  of  the  esophagus;  gastros- 
tomy;  gastrorrhaphy.  A  girl,  aged  16,  had  swallowed  caustic 
potash  when  a  child.  Symptoms  of  cicatricial  stenosis  soon 
set  in  and  two  years  ago  it  became  necessary  to  resort  to  gas- 
trostomy to  prev^ent  death  from  starvation.  The  patient  was 
nourished  through  the  fistula  until  by  the  use  of  a  gradually 
tapering  soft  rubber  bougie  the  stricture  was  sufficiently 
dilated  to  render  the  artificial  opening  superfluous.  The 
patient  is  now  able  to  insert  the  dilator  without  any  difficulty 
and  can  swallow  solid  food  with  ease  and  in  sufficient  quantity, 
hence  it  was  decided  to  close  the  fistulous  opening.  The  opera- 
tion was  performed  under  local  anesthesia  by  Schleich's  infil- 
tration method.  It  was  evident  from  the  patient's  expression 
that  the  operation  was  not  without  pain,  but  she  endured  the 
ordeal  with  patience  and  fortitude.  The  fistulous  opening  was 
circumscribed  by  two  elliptical  incisions,  the  peritoneal  cavity 
opened,  the  anterior  wall  of  the  stomach  drawn  forward  into 
the  wound  in  the  form  of  a  cone  to  the  base  of  which  a  pair  of 
compression  forceps  were  applied.  The  fistulous  opening  was 
closed  by  a  smaller  compression  forceps  and  between  the  two 
forceps  the  excision  was  made  which  left  a  small  oval  visceral 
wound,  this  was  sutured  with  two  rows  of  fine  silk  sutures. 
Three  rows  of  silk  sutures  were  employed  in  closing  the 
abdominal  incision. 

The  outdoor  department  of  Prof.  Eiselsberg's  clinic  is  con- 
ducted in  a  new  building,  admirably  adapted  for  the  treatment 
of  polyclinic  patients.  The  reception  and  examination-rooms 
leave  nothing  to  be  desired  and  the  small  operating-room  is 
supplied  with  everything  necessary  for  aseptic  work.  Here 
many  minor  operations  are  performed  by  his  assistants. 

Professor  Gussenhauer's  CTmzc— Gussenbauer  is  Billroth's 
successor.  After  the  death  of  the  great  master  discussion  was 
rife  among  the  Austrian  and  German  surgeons  as  to  who  would 
in  all  probability  be  called  upon  to  fill  the  vacancy.  It  was 
generally  conceded  that  the  choice  would  naturally  fall  upon 
one  of  his  assistants  who  had  won  distinction  by  original 
scientific  work.  The  final  decision  ended  in  the  appointment 
of  Gussenbauer,  who  for  many  years  was  professor  of  surgery 
in  the  Prague  University.  Under  Billroth  he  and  Wolffler 
made  the  experiments  on  animals  which  in  their  results  proved 
the  feasibility  of  partial  gastrectomy  for  carcinoma  and  circum- 
scribed inflammatory  diseases  and  which  laid  the  foundation 
for  gastric  surgery.  Gussenbauer's  experimental  studies  on 
the  repair  of  wounds  made  his  name  familiar  in  scientific  surgi- 


6 


cal  literature.  His  artificial  larynx  demonstrated  his  mechani- 
cal genius.  His  successful  career  in  Prague  recommended  him 
as  a  worthy  successor  of  his  famous  teacher. 

The  amphitheater  in  which  he  gives  his  clinics  remains  the 
same  as  when  Billroth  left  it.  It  is  a  clinic  in  which  more  dis- 
tinguished surgeons  have  sought  postgraduate  instruction 
than  in  any  other.  The  plain  wooden  benches,  the  narrow 
arena,  the  low  ceiling,  the  simple  instrumentarium  remind  one 
of  the  time  Avhen  the  greatest  surgical  genius  held  here  the  most 
distinguished  clinical  audiences  spellbound  by  his  matchless 
work.  Gussenbauer  is  not  a  Billroth,  but  he  is  a  great  surgeon 
and  a  most  excellent  teacher.  His  language  is  short  and  pre- 
cise, his  diagnostic  conclusions  accurate,  drawn  as  they  always 
are  from  the  pathologic  conditions  presented  by  the  case  under 
consideration.  His  operative  technic  is  well  planned  and  is 
always  carried  out  with  care  and  deliberation.  At  the  time  of 
my  visit  he  was  making  preparations  to  leave  the  city  for  his 
summer  vacation  and  had  turned  over  the  operative  work  to  his 
first  assistant.  Dr.  Salzer,  but  he  was  kind  enough  to  show  me 
some  of  the  more  important  cases  operated  upon  during  the  last 
semester.  Among  these  was  a  case  of  sarcoma  of  the  brain 
operated  upon  by  osteoplastic  resection  of  the  skull.  The  focal 
symptoms  left  no  doubt  as  to  the  exact  location  of  the  tumor. 
A  gradually  appearing  hemiplegia  on  the  right  side  and  aphasia 
pointed  to  the  left  motor  tract  as  the  seat  of  the  disease.  The 
wound  healed  by  primary  intention  and  the  pressure  symp- 
toms were  relieved  by  the  operation.  A  case  of  obstinate  neu- 
ralgia of  thetrigeminous  was  promptly  relieved  by  removal  of 
the  gasserian  ganglion.  His  experience  with  this  operation  has 
been  uniformly  satisfactory.  A  number  of  appendicitis  cases 
were  shown,  the  patients  having  recently  been  operated  upon; 
all  of  them  were  on  the  way  to  a  speedy  recovery.  Several  other 
cases  were  under  observation  and  under  conservative  treat- 
ment. 

Three  cases  of  ununited  fracture  of  the  shaft  of  the  long 
bones  had  been  treated  by  exposing  the  seat  of  fracture  and 
immobilization  by  direct  fixation  with  Gussenbauer's  clamp, 
and  all  of  the  patients  were  doing  well.  A  case  of  recurring 
carcinoma  of  the  orbit  made  it  necessary  to  resect  the  frontal 
bone  and  the  dura  mater  extensively,  and  the  defect,  as  large 
as  the  palm  of  the  hand,  was  filled  in  with  a  celluloid  plate. 
The  large  wound  healed  by  primary  intention.  Gussenbauer 
makes  no  display  of  aseptic  precautions  in  his  clinic.  Turbans, 
gloves  and  masks  are  not  seen,  but  the  hands,  instruments  and 
field  of  operation  are  prepared  with  utmost  care.  Catgut  is 
used  only  in  exceptional  cases.  Dr.  Salzer  made  an  exploratory 
laparotomy  in  a  case  of  far  advanced  carcinoma  of  the  stomach. 


Owing  to  the  extent  and  location  of  the  disease  gastroenteros- 
tomy was  not  indicated,  and  a  radical  operation  was  out  of 
question.  The  same  forenoon  he  operated  on  a  case  of  carci- 
noma of  the  bladder. 

The  patient,  a  middle-aged  man,  had  suffered  for  several 
months  from  irritation  of  the  bladder,  and  recently  hematuria. 
He  was  anesthetized  and  placed  in  Trendelenburg's  position. 
The  interior  of  the  bladder  was  exposed  by  a  median  vertical 
incision.  The  carcinoma  involved  the  base  of  the  bladder  and 
the  vesical  end  of  the  left  urethra.  The  entire  thickness  of  the 
wall  of  the  bladder  at  a  safe  distance  from  the  margins  of  the 
tumor  and  half  an  inch  of  the  vesical  end  of  the  urethra  were 
resected.  The  operation  was  an  exceedingly  difficult  one  and 
was  executed  with  the  utmost  care  and  great  skill.  Buried 
sutures  of  catgut  were  used  in  diminishing  the  size  of  the 
cavity  behind  the  resected  part  of  the  bladder  and  in  implant- 
ing the  urethra  and  suturing  of  the  vesical  wound.  The 
anterior  incision  was  only  sutured  in  part,  leaving  a  large 
opening  for  drainage.  The  drainage  opening  in  the  bladder 
was  sutured  to  the  fascia  of  the  recti  muscle  with  fine  silk. 
The  patient  was  progressing  favorably  24  hours  after  operation. 

Vienna,  July  19. 


[Reprinted  from  American  Medicine,  Vol.  IV,  No.  18,  pages  709-711 
November  1,  1902.] 


SURGICAL  WORK  OF  PROFESSOR  VON  MOSETIG- 
MOORHOF  IN  THE  VIENNA  ALLGEMEINE 
KRANKENHAUS. 

BY 

NICHOLAS  SENN,  M.D., 
of  Chicago. 

The  best  surj^ical  work  is  not  always  done  in  surgical  clinics. 
The  clinical  teacher  has  to  contend  with  many  things  that 
divert  his  attention.  He  is  naturally  anxious  to  build  up  or 
maintain  the  reputation  of  his  clinic  and  must  use  his  material 
for  the  instruction  of  a  critical  audience.  The  surgeon  who  can 
give  his  undivided  attention  to  the  work  before  him  can  attend 
to  many  little  details  which  often  escape  the  notice  of  the  lec- 
turer, or  which,  for  want  of  time,  must  be  referred  to  an  assist- 
ant. The  most  careful  and  painstaking  operator  I  saw  during 
my  whole  trip  through  three  continents  was  Professor  von 
Mosetig-Moorhof,  of  Vienna.  He  is  in  charge  of  one  of  the  five 
surgical  services  of  the  AUgemeine  Krankenhaus.  In  the  two 
divisions  under  von  Eiselsberg  and  Gussenbauer  the  medical 
students  of  the  university  receive  their  clinical  instruction. 
The  other  three  services  are  under  the  care  of  Professor  von 
Mosetig-Moorhof,  Professor  Lang  and  Professor  Hochenegg. 
Professor  Lang's  material  is  made  up  largely  of  venereal  cases. 
The  curative  power  of  the  Finsen  light  in  the  treatment  of 
tuberculous  affections  of  the  skin  is  being  tested.  Experience 
so  far  has  shown  that  the  treatment  requires  much  time,  on  an 
average  daily  sittings  for  a  year,  but  if  carried  out  persistently 
yields  good  results.  Each  sitting  lasts  an  hour  and  costs  the 
hospital  $1.20.  The  apparatus  in  use  furnishes  light  for  four 
patients  at  one  time.  The  expert  in  charge  marks  the  particular 
spot  which  is  to  be  subjected  to  the  light  treatment,  and  nurses 
and  patients  make  the  application.  Under  pressure  the  tissues 
to  be  acted  upon  by  the  light  are  made  bloodless  so  long  as  the 
treatment  lasts,  otherwise  the  action  of  the  light  is  useless.  In 
most  instances  the  application  results  in  the  formation  of  a 
blister.  Counter  irritation  and  tissue  stimulation  are  evidently 
the  most  important  curative  effects  of  the  application.  In  all 
recent  cases  a  decided  reaction  in  the  diseased  tissues  is  always 
very  noticeable.  As  the  disease  yields,  the  tissues  become  paler 
and  shrink.  When  ulcerations  are  present,  the  defects  heal 
by  the  formation  of  a  pale,  pliable,  smooth  scar.  Reports  from 
other  clinics  seem  to  show  that  relapses  after  apparent  cures  are 
by  no  means  uncommon.    I  saw  several  patients  with  extensive 


lupus  of  the  face  who  were  being  treated  by  exposures  to  the 
Rontgen  ray  on  one  side  and  the  Finsen  light  on  the  other.  The 
effects  of  the  Rontgen  ray  are  more  pronounced,  quicker,  and 
the  course  of  treatment  much  shorter  than  that  of  the  Finsen 
light.  Professor  Lang  is  a  well-recognized  expert  in  plastic 
work  with  Thiersch's  skin  grafts  in  covering  large  skin  defects. 
His  cosmetic  results  are  marvelous.  Hochenegg  has  recently 
been  promoted  to  a  professorship  and  placed  in  charge  of  one  of 
the  surgical  divisions.  He  is  a  young  surgeon  of  great  promise, 
whose  name  has  already  found  a  permanent  place  in  surgical 
literature.  His  work  in  abdominal  and  pelvic  surgery  is  well 
known  and  thoroughly  appreciated.  I  now  come  to  the  Vienna 
surgeon  whose  work  I  studied  with  so  much  interest  and  profit 
—Professor  von  Mosetig-Moorhof.  His  personal  appearance  is 
very  striking.  He  is  64  years  of  age,  tall,  erect,  with  a  full 
flowing,  well-trimmed  beard.  His  eyes  are  blue  and  reflect  the 
nobleness  of  his  soul.  In  a  crowd  of  people  his  appearance 
would  always  attract  attention.  He  has  been  a  diligent  student 
since  the  time  of  his  graduation  in  1863  and  is  familiar  with  the 
teachings  and  practice  of  all  surgical  authorities  in  the  world. 
He  is  a  patient  worker,  who  takes  few  and  but  short  vacations. 
His  greatest  pleasure  in  life  is  to  be  among  his  patients  and  to 
relieve  them  of  their  sufferings  by  his  operative  skill.  His 
division  of  128  beds  is  always  crowded.  He  is  more  than  sur- 
geon to  his  appreciative  patients ;  he  is  likewise  their  friend, 
who  takes  more  than  a  scientific  interest  in  their  welfare.  He 
visits  his  wards  regularly  every  morning  at  8.30  o'clock,  exam- 
ines all  new  cases  with  the  utmost  care,  visits  every  patient 
recently  operated  upon  and  then  begins  his  operative  work, 
seldom  leaving  the  hospital  before  the  clock  in  the  tower  strikes 
12.  He  is  assisted  in  his  work  by  a  number  of  faithful  Sisters 
and  three  resident  surgeons.  His  contributions  to  surgical 
literature  have  been  many  and  of  far-reaching  importance.  His 
work  on  operative  surgery  is  very  popular  and  will  soon  appear 
in  its  fifth  edition.  It  is  a  book  that  reflects  the  ripe  experience 
of  its  author  and  on  every  page  will  be  found  good,  sound 
advice.  The  most  careful  aseptic  precautions  are  observed  in 
the  well-equipped  and  well-lighted  operating-room.  The  few 
visitors  who  attend  the  operations  are  each  required  to  wear  a 
linen  coat.  The  white  aseptic  cap  is  worn  by  the  operator  and 
assistants  only  during  abdominal  work.  Gloves  and  masks  are 
not  in  use.  Hand  disinfection  is  made  by  thorough  scrubbing 
with  soap  and  hot  water,  followed  by  marbledust  soap,  alcohol 
and  sublimate.  The  field  of  operation  is  shaved  and  disinfected 
in  a  similar  manner  after  the  patient  is  fully  under  the  influ- 
ence of  the  anesthetic,  either  chloroform  or  the  A.  C.  E.  mix- 
ture.   The  operator  wears  knit  sleeves.    Fine  silk  boiled  in  5% 


solution  of  carbolic  acid  and  kept  in  sublimate  alcohol  is  the 
favorite  material  for  sutures  and  ligatures.  Before  each  abdom- 
inal operation  the  silk  is  reboiled.  Stitch  abscesses  are 
unknown,  the  best  possible  proof  of  the  care  taken  in  preparing 
the  silk. 

Directions  for  Catgut  Sterilization.— The  following  are  the 
directions  given  for  the  sterilization  of  catgut: 


Iodoform  plomb,  four  weeks  after  resection  of  the  wrist  joint. 

1.  Immerse  the  raw  material  for  24  to  48  hours  in  sulfuric 
ether. 

2.  Immerse  for  8  to  10  days  in  96%  alcohol  and  change  the 
fluid  frequently  so  long  as  it  becomes  turbid. 

3.  Place  catgut  in  a  1%  alcoholic  solution  of  mercury  bichlo- 
rid  for  three  days. 

4.  Keep  for  one  day  in  96%  of  alcohol. 

5.  Preserve  in 

Bichlorid  of  mercury LO 

Glycerin 50.0 

Alcohol 1,000.0 


Professor  Mosetig-Moorhof  is  never  in  a  hurry  when  oper- 
ating. He  makes  his  plans  beforehand  deliberately  and 
executes  them  with  the  hand  of  a  master.  Every  motion  he 
makes  with  knife,  needle  or  spongre  is  for  a  distinct  purpose. 
He  does  not  know  confusion  nor  surprise,  and  when  something 
unexpected  arises  he  is  prepared  for  the  emergency.  His 
knowledge  of  minute  anatomy  makes  the  finest  dissections  a 
source  of  delight  to  him.  In  doubtful  cases  he  exhausts  all 
modern  diagnostic  resources  before  he  makes  a  final  diagnosis, 
and  if  this  cannot  be  done  he  relies  on  the  knife  to  clear  up  the 
doubt.  His  patients,  young  and  old,  come  to  the  operating- 
room  without  doubt  and  without  fear,  with  implicit  confidence 
in  the  man  who  is  to  hold  their  lives  in  his  hands.  It  is  a  source 
of  genuine  pleasure  to  accompany  this  surgeon  on  his  daily 
visits  through  the  wards.  He  is  greeted  everywhere  by  pleas- 
ant, smiling  faces.  There  are  no  indications  of  mistrust  or 
dissatisfaction,  and  he  has  for  all  a  pleasant  word  or  a  friendly 
nod. 

Mosetig-Moorhof  s  Iodoform  Plomh.  —  For  a  number  of 
years  von  Mosetig-Moorhof  has  made  use  of  a  preparation  of 
iodoform  in  filling  bone  cavities  after  operations  for  tubercu- 
losis or  osteomyelitis.  This  antibacillary  agent  is  used  in  the 
following  form : 

lodoformi 40.0 

Cetacei 

01.  sesami aa  30.0 

The  menstruum  is  thoroughly  sterilized  by  boiling.  The 
iodoform  finely  pulverized  and  sterilized  is  slowly  added  to  the 
mixture  and  agitated  constantly  until  it  cools  oflt"  to  ensure  a 
uniform  dissemination  of  the  iodoform  throughout  the  mass, 
which  solidifies  at  an  ordinary  temperature.  After  the  cavity 
is  prepared  the  mixture  is  heated  and  in  a  fluid  state  is  poured 
into  it,  when  it  again  becomes  firm  and  fills  the  cavity  like 
dentist's  amalgam  in  a  carious  tooth.  The  Rontgen  rays 
show  the  exact  location,  size  and  form  of  the  iodoform  plomb 
in  the  interior  of  the  bone.  The  x-ray  also  shows  the  process  of 
healing  by  the  gradual  disappearance  of  the  iodoform  through 
absorption  and  substitution  of  granulations  for  the  absorbable 
temporary  packing.  Cavities  in  the  epiphyseal  extremities 
after  resection  for  tuberculosis,  treated  in  this  manner  heal  in 
the  course  of  a  few  weeks,  and  the  use  of  the  Rontgen  ray  at 
any  time  will  demonstrate  their  gradual  diminution  in  size  and 
the  slow  absorption  of  the  iodoform  plomb.  In  extensive  oper- 
ations for  necrosis  large  cavities  are  filled  with  this  material 
and,  as  is  often  the  case,  if  the  cavity  is  not  entirely  aseptic  the 
foreign  material  is  gradually  discharged  in  small  fragments  as 
the  cavity  diminishes  in  size.    The  greatest  benefit  from  this 


method  of  packing  a  bone  cavity,  however,  is  derived  in  cases 
of  tuberculous  foci  in  the  articular  ends  of  the  long  bones.  I 
have  used  for  many  years  with  signal  success  decalcified  iodo- 
formized  bone  chips  in  the  same  class  of  cases,  but  from  what  I 


Iodoform  ploinb,  five  weeks  after  operation. 

saw  in  the  practice  of  von  Mosetig-Moorhof  I  am  inclined  to 
give  his  method  a  faithful  trial. 

Tegmm. —Tegmin  is  a  white,  aseptic,  adhesive  substance 
which  is  used  as  a  substitute  for  collodion  in  sealing  small 
wounds  that  do  not  require  drainage.  It  has  the  great  advan- 
tage over  collodion  in  being  absolutely  aseptic  and  can  be 
readily  washed  away  with  warm  water. 

Stricture  of  the  Esophagus.— 1  was  astonished  to  find  so 


many  strictures  of  the  esophagus  in  the  Allgemeine  Krauken- 
haus.  I  saw  one  case  in  Gussenbauer's  clinic,  and  another  in 
von  Eiselsberg's,  and  three  cases  in  von  Mosetig-Moorhof's 
wards.  In  all  of  them  the  stricture  followed  the  accidental 
drinking  of  lye,  and  in  all  it  became  necessary  to  perform 
gastrostomy  to  prevent  death  from  starvation  and  to  prepare 
the  way  for  successful  treatment  by  gradual  dilation.  In  the 
last  three  cases  mentioned  the  gastric  fistula  had  closed  or  was 
closed  by  operation,  and  the  treatment  by  gradual  dilation  was 
progressing  satisfactorily.  In  one  case  the  stricture,  a  very 
obstinate  one,  was  finally  passed  by  a  socalled  gravitation 
sound.  A  hollow,  tapering,  soft  rubber  esophageal  tube  was 
filled  with  fine  shot.  It  was  inserted  as  far  as  the  stricture,  and 
by  its  own  weight 
suddenly  forced  its 
way  through,  an  oc- 
currence which  was 
immediately  recog- 
nized and  announced 
by  the  happy  pa- 
tient. Since  then 
gradual  dilation 
could  be  made  with- 
o  u  t  encountering 
any  particular  diffi- 
culty. The  experi- 
ence here,  like  else- 
where, has  been  to 
the  eff"ect  that  the 
strictures  could  be 
passed  after  gastros- 
tomy was  performed 
although  they  ap- 
peared to  be  abso- 
lutely impermeable 
before  operation.  I 
will  make  brief  men- 
tion of  a  few  opera- 
tions performed  by 
Professor  Mosetig- 
Moorhof  during  my 
visits. 

Resection  of 
Joints  for  Tubercu- 
losis.—T\ie    number 

of  cases  of  tuberculosis  of  joints  under  the  care  of  this  surgeon  is 
unusually  large.   The  brilliant  results  obtained  by  his  thorough 


Iodoform  plorab  in  the  lower  end  of  the  radius 
eight  weeks  after  operation  for  osteomyelitis.  ' 


methods  are  undoubtedly  responsible  for  this.  About  10  cases 
of  resection  of  the  knee  and  elbow-joint  were  shown,  the 
patients  having  been  operated  upon  from  a  few  days  to  two 
months  ago.  In  all,  the  wound  healed  by  primary  intention 
and  the  limbs  were  in  a  useful  position.  In  elbow-joint  resec- 
tions the  olecranon  process  is  temporarily  detached,  and  after  the 
resection  is  completed  is  united  with  the  shaft  of  the  ulna  with 
aluminum-bronze  wire  sutures.  Several  patients  who  had 
this  joint  resected  for  extensive  tuberculous  disease  were  shown 
who  had  recovered  with  useful  movable  joints.  The  exter- 
nal incision  is  made  transversely  over  the  base  of  the  olecranon 
process.  In  resection  of  the  knee-joint,  Langenbeck's  trans- 
verse incision  is  the  one  usually  chosen  in  exposing  the  interior 
of  the  joint.  The  epiphyseal  cartilages  are  always  saved  and 
the  tuberculous  foci  in  the  articular  ends  are  scraped  out  from 
the  sawed  surface  with  a  sharp  spoon,  and  after  thorough 
cleansing  are  packed  with  the  iodoform  plomb.  The  greatest 
stress  is  laid  on  complete  extirpation  of  the  tuberculous 
synovial  membrane,  capsule,  and  thorough  excision  of  para- 
articular abscesses  and  fistulous  tracts  when  they  exist.  In  one 
case  of  tuberculosis  of  the  knee-joint  with  moderate  swelling, 
but  marked  genu  valgum,  a  tuberculous  focus  was  found  in 
the  internal  condyle  of  the  femur  and  one  in  each  tuberosity 
of  the  tibia.  In  excising  the  capsule  the  incisions  were  carried 
deep  enough  to  expose  healthy  muscles,  tendons  and  fascia. 
Particular  care  was  taken  in  cleaning  out  the  capsule  over  the 
popliteal  space.  In  this  instance  the  patella  was  found  exten- 
sively diseased  and  was  excised.  The  lower  angle  of  the  wound 
on  each  side  was  drained  by  inserting  a  folded  piece  of  gutta- 
percha tissue,  a  favorite  method  of  drainage  with  Mosetig- 
Moorhof.  The  soft  tissues  around  the  resected  bone  ends,  as 
well  as  the  external  wound,  were  sutured  with  fine  silk.  Over 
the  dry,  sterile  hygroscopic  dressing  thin  strips  of  beechwood, 
socalled  shoemaker's  chips,  were  applied  and  held  in  place 
with  a  moist  organtine  bandage.  He  never  uses  plaster-of- 
paris  in  immobilizing  a  limb  after  resection.  The  first  dressing 
remains  for  two  to  three  weeks.  When  the  dressing  is  changed 
the  little  drains  and  sutures  are  removed.  The  line  of  suturing 
is  kept  moist,  and  the  removal  of  the  dressing  and  sutures 
made  easy  by  placing  over  the  first  part  of  the  dressing,  a  few 
layers  of  iodoform  gauze,  an  impermeable  cover  of  mackintosh 
or  guttapercha.  This  cover  prevents  evaporation  and  inspissa- 
tion  of  the  primary  wound  secretion  in  that  part  of  the  dressing. 
The  limb  is  immobilized  in  the  same  manner  after  the  second 
dressing,  Avhichthen  remains  until,  in  cases  of  resection  of  the 
knee-joint,  firm,  bony  consolidation  has  taken  place ;  that  is, 
about  three  months.   In  an  aggravated  case  of  tuberculosis  at  the 


8 

base  of  the  thumb  in  an  adult  the  diseased  joint  surfaces  were 
exposed  by  a  curved  incision  with  the  convexity  directed 
toward  the  radial  side.  The  tendons  and  radial  artery  were 
carefully  held  out  of  the  way  while  the  articular  end  of  the 
proximal  phalanx  of  the  thumb  and  the  articular  end  of  the 
metacarpal  bone  of  the  index  finger  were  resected  and  the 
multangulum  majus  was  extirpated.  The  fistulous  tracts  com- 
municating with  the  primary  seat  of  the  disease  were  thoroughly 
excised  and  the  wound  sutured,  drained  and  dressed  in  the 
manner  described.  The  thoroughness  with  which  all  diseased 
tissue  is  removed  in  all  of  Mosetig-Moorhof  s  operations  for 
tuberculosis,  and  the  prolonged  iodoformization  of  the  original 
foci  of  infection,  account  satisfactorily  for  his  matchless  results. 
Amputations.— Two  amputations  I  witnessed  in  this  great 
clinical  school  for  postgraduate  instruction  demonstrated  the 
technical  skill  of  the  operator  in  this  kind  of  surgical  work. 

The  first  patient  was  a  man,  aged  72,  the  subject  of  extensive 
atheromatous  arterial  degeneration.  Two  toes  adjacent  to  the 
big  toe  were  gangrenous.  For  good  reasons  it  was  deemed 
necessary  to  make  a  high  amputation.  The  Gritti  supracondy- 
loid  amputation  was  made.  The  vivified  surface  of  the  pat- 
ella was  brought  in  accurate  contact  with  the  sawed  surface  of 
the  femur  and  fixed  in  position  with  buried  sutures  Avhich 
included  the  tendon  of  the  patella  and  the  periosteum  and 
paraperiosteal  tissues  of  the  posterior  margin  of  the  end  of 
the  bone.  The  long  oval  anterior  fiap  was  sutured  in  place 
with  silk,  leaving  the  angles  of  the  wound  open  for  the  small 
guttapercha  drains.  After  dressing  the  stump  it  was  immo- 
bilized with  splints  of  wood  shavings.  The  next  day  this 
patient's  condition  was  much  improved  and  he  stated  that 
he  had  been  relieved  of  all  pain  since  the  operation  was  per- 
formed. Every  step  of  the  operation  had  been  performed  with 
a  manual  dexterity  that  charmed  the  few  visitors  and  yet 
without  any  attempt  whatever  at  display. 

In  the  next  case  a  Chopart  amputation  was  made  for  exten- 
sive tuberculosis  of  the  mediometatarsal  joint  of  the  foot. 
The  plantar  flap  extended  as  far  as  the  base  of  the  toes  and 
when  sutured  in  place  covered  the  amputation  wound  in  an 
ideal  manner.  With  deep  silk  stitches  the  extensor  and  flexor 
tendons  were  brought  together  in  closing  the  external  wound. 
The  heel  was  well  supported  with  thin  wooden  splints  applied 
over  the  absorbent  dressing  and  held  in  place  with  a  moist 
organtine  bandage. 

Radical  Operation  for  Hernia.— Frote^sov  von  Mosetig- 
Moorhof  is  partial  to  Bassini's  method  in  operations  for  the 
radical  cure  of  inguinal  hernia.  The  inguinal  canal  is  closed 
underneath  the  spermatic  cord  and  its  accompanying  vessels 
with  not  more  than  four  aluminum-bronze  wire  sutures.  This 
material  has  given  great  satisfaction  in  performing  this  opera- 
tion. The  sutures  can  be  tied  with  the  same  ease  as  silk 
sutures  and  remain  in  the  tissues  indefinitely  without  giving 
rise  to  irritation.    His  patients  are  confined  to  bed  for  three 


9 

weeks,  when  they  are  discharged  without  any  mechanic 
support.    The  remote  results  have  been  very  satisfactory. 

This  operation  was  performed  on  a  woman  suffering  from  a 
direct  inguinal  hernia.  After  resection  of  the  hernial  sac  the 
inguinal  canal  was  closed  with  four  aluminum-bronze  wire 
sutures  and  the  skin  incision  with  fine  silk. 

Gastroenterostomy . — The  patient,  an  aged  emaciated  woman, 
had  been  suffering  from  pyloric  obstruction  for  more  than  a 
year.  Physical  examination  revealed  the  presence  of  marked 
dilation  of  the  stomach.  The  incision  was  made  through  the 
right  rectus  muscle.  The  disease  was  confined  to  the  pylorus, 
and  although  a  number  of  lymphatic  glands  were  found  impli- 
cated, it  was  deemed  a  proper  case  for  a  radical  operation,  which 
would  have  been  performed  if  it  had  not  been  for  the  critical 
general  condition  of  the  patient.  An  anterior  gastroenterostomy 
was  made.  The  position  of  the  intestinal  loop  which  corre- 
sponded to  the  junction  of  the  duodenum  with  the  jejunum  was 
reversed  and  the  mesentery  of  the  small  intestine  was  tunneled 
with  hemostatic  forceps  at  two  points  about  four  inches  apart. 
Through  each  slit  a  heavy  silk  suture  was  drawn  and  tied  so 
as  to  exclude  intestinal  contents  from  the  isolated  portion 
during  the  operation.  After  suturing  the  intestinal  loop  to 
the  stomach,  the  peritoneum,  the  length  of  the  purposed 
anastomosis  over  the  bowel  and  stomach  was  incised  and  with 
a  continuous  fine  silk  suture  the  parts  were  united.  The 
mucous  membrane  was  next  incised  on  both  sides  and 
united  with  the  same  kind  of  a  suture.  The  anterior 
margins  of  the  visceral  wounds  were  united  in  a  similar 
manner.  The  whole  operation  was  completed  in  45  minutes. 
At  no  time  did  the  patient  manifest  the  least  sign  of  shock.  In 
this  instance  the  operation  was  performed  under  general  anes- 
thesia, at  the  special  request  of  the  patient,  although  the  routine 
practice  is  to  operate  under  local  anesthesia.  For  the  purpose 
of  preventing  flexion  of  the  bowel  at  the  anastomotic  opening 
the  proximal  part  of  the  loop  was  sewed  to  the  anterior  surface 
of  the  stomach  to  a  distance  of  at  least  three  inches  from  the 
anastomotic  opening. 

Fluid  food  is  administered  by  the  stomach  a  few  hours  after 
operation,  solid  food  is  withheld  for  four  or  five  days. 

Acute  Osteo7nyelitis.— Several  cases  of  acute  osteomyelitis 
were  operated  upon. 

In  one  case  a  girl,  aged  5,  had  been  ill  only  11  days,  and  was 
admitted  into  the  hospital  with  all  the  signs  and  symptoms  of 
extensive  involvement  of  the  entire  sliaft  of  the  tibia.  The  leg 
was  enormously  swollen,  edematous  and  diffuse  fluctuation 
indicated  the  existence  of  a  large  phlegmonous  abscess.  Free 
incisions  were  made  and  the  greater  part  of  the  tibia  was  found 
denuded  of  its  periosteum.  The  immense  abscess  cavity  was 
washed  out  with  a  formalin  solution,  5  : 1,000,  which  is  used  in 
preference  to  any  other  antiseptic  solution  in  dealing  with  acute 
suppurative  aftections.  The  cavity  was  packed  loosely  with 
gauze  and  a  dry  absorbent  aseptic  dressing  was  applied. 

Laparotomy  for  Volvulus  of  the  Sigmoid  Flexure. — The 
patient,  a  woman  aged  30,  the  subject*  of  a  small  umbilical 
hernia,  was  suddenly  taken  ill  two  days  ago.  She  complained 
of  pain  in  the  umbilical  region.  Abdomen  was  tympanitic.  The 
sac  of  the  umbilical  hernia  was  empty.    There  was  no  vomiting 


10 


but  complete  obstipation.  Diagnosis  of  intestinal  obstruction 
from  some  mechanical  cause  was  made,  but  it  was  impossible 
to  predict  the  location  and  nature  of  the  obstruction.  Abdomi- 
nal incision  was  made  through  the  left  rectus  muscles.  Small 
intestines  were  distended  and  very  vascular.  The  incision  was 
enlarged  and  rapid  eventration  made.  The  prolapsed  intesti- 
nal loops  were  carefully  protected  by  enveloping  them  in 
warm,  moist  compresses.  The  large  intestine  presented  the 
same  appearance.  A  volvulus  of  the  sigmoid  flexure  was  dis- 
covered as  the  cause  of  the  obstruction.  The  malposition  was 
quickly  corrected,  the  intestines  reduced  and  the  large  abdomi- 
nal incision  closed  with  three  rows  of  fine  silk  sutures.  The 
next  day  this  patient  was  found  in  excellent  condition.  An 
early  operation  had  been  the  means  of  preventing  textural 
changes  in  the  twist  of  the  sigmoid  flexure  which  when  once 
^pveloped  render  further  operative  interference  almost  hope- 
less. 

Vienna,  July  20. 


[Keprinted  from   American  Medicine,  Vol.  IV,  No.  19,  pages  743-746 
November  8,1902.1 


MEDICAL  LONDON  IN  SUMMER. 

BY 

NICHOLAS  SENN,  M.D., 
of  Chicago. 

Summer  is  not  a  good  time  to  see  medical  London  at  its  best, 
as  the  teachers  and  distinguished  men  in  medicine  and  surgery- 
take  their  much-needed  vacation  about  the  middle  of  July.  The 
English  doctor  knows  where  and  how  to  spend  his  days  of  rest. 
Many  of  the  ambitious,  restless  American  doctors  utilize  their 
vacation  in  making  long  journeys,  visiting  hospitals,  labora- 
tories and  libraries,  with  a  view  of  increasing  their  store  of 
knowledge,  returning  to  their  work  in  a  worse  mental  and  physi- 
cal condition  than  when  they  left  it.  Not  so  with  the  average 
ICnglish  doctor.  He  knows  the  necessity  of  an  entire  change  in 
thought,  surroundings  and  daily  habits  of  life,  and  governs  him- 
self accordingly.  He  seldom  crosses  the  channel,  and  very 
rarely  undertakes  an  ocean  voyage.  The  island  kingdom  is  his 
favorite  resting  place.  In  a  few  hours  he  is  at  a  safe  distance 
from  a  noisy  city  practice  in  full  enjoyment  of  a  comfortable 
summer  home,  in  a  quiet  environment  that  suits  his  tastes,  or 
at  a  well-conducted  seashore  or  mountain  retreat.  Here  he 
remains  until  the  long  shadows  of  the  September  sun  remind 
him  of  his  duties  to  his  clients  and  the  institutions  he  repre- 
sents, when  he  hastens  home  with  the  body  revived  and  the 
mental  activities  renewed,  and  resumes  his  work  with  a  vigor 
and  enthusiasm  that  he  found  flagging  at  the  end  of  a  busy  year 
weeks  before  his  departure.  During  his  absence  the  most 
necessary  hospital  and  private  work  is  done  by  one  or  more 
young  assistants,  but  enough  material  has  accumulated  upon 
his  return  to  engage  at  once  his  whole  time  and  attention.  He 
finds  after  his  well-spent  vacation  that  work  has  become  a 
source  of  pleasure  instead  of  the  unavoidable  necessary  task  it 
was  when  he  left  it.  With  what  interest  and  care  the  surgeon 
examines  his  patients,  and  how  deliberately  and  skilfully  he 
wields  his  scalpel,  and  with  what  precision  he  grasps  bleeding 
vessels  on  his  return  from  his  long  summer  vacation !  His  eye- 
sight is  keener,  his  hands  more  steady,  his  step  more  elastic, 
his  actions  more  deliberate  and  his  sallow,  careworn  face  is 
covered  with  a  living  mask  of  ruddy,  sunburned  skin.  It  only 
takes  from  eight  to  ten  months  to  wear  off  what  was  gained  by 
the  much-needed  vacation,  when  in  justice  to  himself,  to  his 


profession  aud  his  patients  lie  again  abandons  his  rontine 
work  and  seeks  rest  and  recreation.  Of  all  learned  professions 
the  medical  is  the  one  in  greatest  need  and  most  deserving  of  a 
long,  free-of-eare  annnal  vacation.  It  is  hard  to  make  the  public 
understand  this,  but  it  is  nevertheless  true.  During  the  sum- 
mer months  the  complicated  machinery  of  the  law  comes  to  a 
standstill,  and  the  lawyers  take  their  vacation  Avithout 
crippling  their  bank  account  to  any  extent.  The  fashionable 
churches  close  their  doors  when  the  members  of  the  congrega- 
tions go  to  their  luxurious  summer  homes,  and  the  rectors  and 
preachers,  with  purses  well  filled  with  gold  by  their  grateful 
parishioners  for  their  vacation  expenses,  leave  the  great  cities 
and  spend  their  allotted  leisure  weeks  and  months  where  they 
are  sure  to  find  rest,  comfort  and  recreation.  It  is  the  doctor 
who  is  expected  to  work  from  one  end  of  the  year  to  the  other. 
It  is  the  doctor  who  must  pay  full  rate  traveling  and  hotel 
expenses  when  he  tears  himself  away  from  his  work  for  a  short 
vacation.  It  is  the  doctor  whose  annual  income  suffers  when 
he  leaves  his  practice  for  a  much-needed  outing.  It  is  the 
doctor  who  carries  away  with  him  the  weight  of  his  responsi- 
bilities to  a  greater  extent  than  the  members  of  any  other  pro- 
fession when  away  from  daily  routine  work. 

The  public  must  be  made  to  understand  that  medical  men 
are  entitled  above  any  other  profession  or  class  of  men  to  an 
annual  vacation,  and  that  such  vacation,  properly  spent,  will 
bring  to  patients  better  service,  and  will  be  one  of  the  most 
important  factors  in  promoting  the  science  of  medicine,  public 
hygiene  and  sanitation.  In  London,  like  in  all  large  cities  in 
Great  Britain  and  on  the  Continent,  most  of  the  clinical  work 
during  the  months  of  July  and  August  is  done  by  the  working 
assistants,  whose  teachings  and  operations  are  usually  credit- 
able reflections  of  the  practice  of  their  chiefs.  In  many  of  the 
surgical  clinics,  for  instance,  the  first  assistant  operates  as  well 
and  in  some  instances  better  than  his  master.  The  visiting 
doctor,  however,  is  always  desirous  of  witnessing  the  work  of 
men  whose  names  have  become  famous  in  medical  or  surgical 
literature,  hence  he  is  often  disappointed  in  visiting  clinics 
during  vacation  months.  For  profitable  laboratory  study  and 
clinical  instruction  in  small  classes,  under  competent  assist- 
ants, the  summer  months  offer  many  inducements  to  students 
and  physicians  from  foreign  countries.  The  rich  anatomic  and 
pathologic  museums  of  the  College  of  Physicians  and  Surgeons, 
and  of  the  numerous  hospitals  in  London,  alone  would  furnish 
rare  object  studies  for  an  entire  summer  to  students  desirous  of 
becoming  thoroughly  grounded  in  the  two  most  important 
fundamental  branches  of  medicine  and  surgery — anatomy  and 
pathology.    Anatomy  is  taught  more  thoroughly  in  England 


8 


than  in  any  other  couutry.  Vienna  leads  in  pathology  and 
Berlin  in  bacteriology  and  clinical  instruction.  There  are  too 
many  hospitals  and  medical  colleges  in  London.  The  govern- 
ment does  little  or  nothing  toward  the  support  of  medical  edu- 
cation, and  the  hospitals  have  to  rely  largely  for  their  support 
on  private  contributions.  It  is  not  unusual  to  tind  in  any  of  the 
great  daily  papers  an  appeal  to  the  public  from  a  number  of 
hospitals  for  support,  showing  their  pressing  need  of  financial 
aid  to  meet  current  expenses.  With  the  exception  of  St. 
Thomas',  most  of  the  hospitals  are  small,  and  as  nearly  all  of 
them  have  their  own  college,  it  is  easy  to  see  that  the  clinical 
material  is  inadequate,  and  that  the  necessary  improvements 
are  not  made  as  promptly  as  the  increasing  demands  require. 
If  London  had  one  large,  general  hospital  under  the  control  of, 
and  supported  by  the  government,  and  in  connection  with  a 
great  medical  school,  the  cause  of  medical  education  and  post- 
graduate instruction  in  England  would  be  materially  advanced. 
All  of  the  existing  medical  schools  do  excellent  work,  and  their 
graduates  compare  favorably  with  those  of  the  continental  uni- 
versities, but  the  practical  training  could  be  conducted  in  a 
much  more  satisfactory  and  efficient  manner  in  a  school  in  con- 
nection with  a  large,  general  hospital  under  government 
control. 

The  British  Medical  Association  is  the  largest  organization 
of  medical  men  in  the  world.  It  has  reached  the  mature  age  of 
70  and  embraces  the  majority  of  the  practitioners  of  the  island 
kingdom  and  of  its  numerous  colonies.  It  owns  a  central  home 
on  the  Strand  in  the  very  heart  of  London,  which  has  been 
acquired  at  an  enormous  expense.  The  official  organ  of  the 
association.  The  British  Medical  Journal,  has  the  largest  circu- 
lation of  any  similar  publication  in  the  world.  Through  the 
able  business-like  management  of  Mr.  Ernest  Hart,  its  late 
editor,  the  journal  has  become  a  source  of  income  instead  of  a 
financial  burden  to  the  association.  The  income  from  legitimate 
advertisements  last  year  amounted  to  ^97,H75.  Good  manage- 
ment of  the  business  atfairs  of  the  association  has  placed  it  upon 
a  sound  financial  basis.  Last  year  |1,875  was  voted  for  scientific 
research  and  ^3,250  for  scientific  research  scholarships.  Since  1874 
the  association  has  appropriated  out  of  its  funds  for  scientific 
research  $85,115.  This  is  an  example  worthy  of  imitation  by  the 
American  Medical  Association.  So  long  as  the  governments  and 
the  public  in  England  and  America  take  so  little  interest  in  medi- 
cal scientific  research  it  becomes  the  duty  of  the  profession  not 
only  to  do  the  work  gratuitously  but  also  to  contribute  the  neces- 
sary means  to  advance  the  science  of  medicine.  The  present  mem- 
bership of  the  association  is  18,758.  Much  of  the  scientific  work 
is  done  in  the  many  branches  of  the  association  in  the  island 


kingdom  and  its  c't)lonial  possessions  throughout  the  civilized 
world.  The  annual  meeting  is  devoted  largely  to  social  func- 
tions and  entertainments  of  all  kinds.  The  working  hours  are 
from  10  a.m.  until  1  p.m.  The  English  physicians  enjoy  such 
diversions.  These  entertainments  include  many  out^door  amuse- 
ments. What  is  expected  of  the  visitors  in  a  social  way  may  be 
learned  by  a  glance  at  the  following  social  program  furnished 
this  year : 

1.  Official  opening  of  the  Annual  Museum  and  Exhibition. 

2.  Garden  Party  by  Mr.  and  Mrs.  Edward  Donner. 

3.  Soiree  at  the  Owen  College  by  the  President  and  Local 
Executive  Committee. 

4.  Excursion  to  Blackpool. 

5.  Garden  Party  by  Dr.  and  Mrs.  Mould. 

6.  Garden  Party  by  Mr.  and  Mrs.  H.  H.  Smith-Carrington. 

7.  Reception  and  Fete  in  Whitworth  Park  by  the  President 
and  Local  Executive  Committee. 

8.  Garden  Party  ])y  Mrs.  Rylands. 

9.  Annual  Dinner  of  the  Association. 

10.  Ladies'  Reception  and  a  Variety  Entertainment  at  the 
Princess  Theatre. 

11.  Garden  Party  by  the  Council  of  Owen  College  and  the 
President  of  the  Manchester  Medical  Society. 

12.  Garden  Party  by  the  Mayor  of  Salford. 

13.  Lord  Mayor  of  Manchester's  Conversazione  in  the  Town 
Hall. 

14.  Ball,  given  by  the  President  and  Local  Executive  Com- 
jnittee. 

15.  Visit  to  Crewe  Works. 

16.  Excursion  to  Bury. 

17.  Excursion  to  Northwich. 

18.  Excursion  to  Southport. 

19.  Excursion  to  Windermere. 

20.  Excursion  to  Lancaster. 

21.  Excursion  to  Chester  and  North  Wales. 

22.  Excursion  to  Colwyn  Bay  and  Conway. 

23.  Excursion  to  Llambevis,  Snowden,  etc. 

24.  Excursion  to  Haddon  Hall  and  Chatsworth. 

25.  Excursion  to  Lake  District. 

The  effect  of  so  many  entertainments  was  made  manifest  in 
the  general  and  section  meetings,  many  of  which  were  scantily 
attended.  During  the  midst  of  a  meeting  of  the  Gynecologic 
and  Obstetric  Section  I  counted  30  members  in  attendance  and 
in  the  Surgical  Section  there  were  seldom  more  than  100  present 
at  any  one  time.  The  Manchester  meeting  was  presided  over 
by  Mr.  Walter  Whitehead,  F.R.C.S.  (Edin.),  F.R.S.E.,  a  sur- 
geon of  great  repute.  It  is  one  of  the  customs  of  the  British 
Medical  Association  to  select  its  president,  orators  and  chair- 
men of  the  different  sections  from  the  local  profession  of  the 
city  in  which  the  meeting  is  held.  This  plan  has  much  to 
recommend  it  as  it  gives  the  local  physicians  a  recognition 
which  they  as  well  as  the  public  appreciate  and  limits  the 
honors  of  the  association  to  the  men  who  have  to  do  the  hard 


work  to  make  the  meetiDg  a  success.  Tlie  president's  address 
as  well  as  the  addresses  in  medicine  by  Sir  Thomas  Barlow  and 
in  obstetrics  by  Professor  W.  Japp  Sinclair  were  well  received. 
The  subjects  for  the  work  of  the  diflterent  sections  were  selected 
and  arranged  with  care.  The  discussions  were  characterized 
by  harmony  and  brought  out  much  valuable  pathologic  and 
clinical  information  from  the  varied  and  extensive  experiences 
and  observations  of  the  different  speakers.  Tuberculosis  of  the 
genitourinary  organs,  prostatectomy  and  the  palliative  treat- 
ment of  carcinoma  were  the  principal  subjects  discussed  in  the 
Surgical  Section. 

Drs.  Alexander  and  Parker  Syms,  of  New  York,  took  a 
leading  part  in  the  discussion  of  prostatectomy,  and  their 
remarks  made  a  deep  and  favorable  impression. 

Coro7iation  Honors  for  Medical  J/e«.— The  King  has  no 
more  loyal  subjects  in  his  vast  empire  than  the  physicians. 
When  the  South  African  war  broke  out  the  most  distinguished 
surgeons  with  princely  incomes,  moved  by  the  purest  patriotic 
feelings,  offered  their  services  to  their  country.  Sir  William 
MacCormac,  Sir  William  Stokes,  Mr.  Frederick  Treves,  Mr. 
Thomas  Jones,  and  many  others  took  the  field  regardless  of 
many  unavoidable  privations  and  a  hostile  climate,  and  in  a 
most  unselfish  manner  gave  their  services  to  the  sick  and 
wounded.  Their  unselfish,  patriotic  deeds  cannot  be  estimated 
in  money  value.  They  risked  their  lives,  and  Sir  William 
Stokes,  Mr.  Thomas  Jones,  and  many  others  found  an  honor- 
able soldier's  grave.  His  Majesty  has  recognized  the  patriotism 
and  valor  of  his  medical  subjects  and  has  been  liberal  in  the 
distribution  of  honors.  The  council  of  the  British  Medical 
Association  has  this  to  say  on  the  subject  in  their  report  for  this 
year: 

"  The  council  has  noted  with  much  satisfaction  the  honors 
conferred  upon  members  of  the  association  by  the  King  in  con- 
nection with  his  coronation.  More  especially  are  congratula- 
tions tendered  to  Sir  Victor  Horsley,  whose  work  in  connection 
with  the  association  the  council  is  glad  to  acknowledge." 

Of  the  knighthood  recently  bestowed  upon  Scotland's  most 
distinguished  surgeon,  William  Macewen,  the  Edinhiirgh 
Medical  Journal  says : 

"Sir  William  Macewen,  professor  of  surgery  in  the  Tiiiver- 
sity  of  Glasgow,  has  achieved  by  his  contributions  to  surgical 
science  such  a  reputation  that  his  clinic  has  become  a  Mecca  to 
which  pilgrims  are  drawn  from  all  parts  of  the  world." 

The  successful  operation  performed  upon  His  Majesty  by 
Sir  Frederick  Treves  for  appendicitis  has  made  for  tJiis  eminent 
surgeon  a  lasting  reputation,  and  his  grateful  royal  patient  will 
know  best  how  to  remunerate  him  for  his  skilful  life-saving 
service.    The  King  has  had  a  personal  experience  with  what 


modern  surgery  can  do  in  averting  death  and  alleviating  pain, 
and  in  view  of  his  speedy  and  satisfactory  recovery  by  opera- 
tive intervention  from  a  dangerous  disease,  we  may  expect  in 
the  near  future  a  perfect  shower  of  honors  upon  deserving 
medical  men  outside  of  those  wh<^  are  in  immediate  charge  of 
the  nation's  patient. 

Two  Interesting  Surgical  Operations  by  Sir  Victor  Horsley. 
—Victor  Horsley  is  continuing  his  scientific  researches  on  brain 
localization.  He  is  a  tireless  and  systematic  investigator.  As 
an  intracranial  surgeon  he  has  no  superior.  As  a  diagnostician 
of  brain  lesions  he  has  no  equal.  His  knowledge  of  the  minute 
anatomy  of  the  brain  and  the  functions  performed  by  its 
various  parts,  and  the  disturbance  of  these  functions  by  definite 
pathologic  processes,  enable  him  to  recognize  and  locate  affec- 
tions anienal)le  to  successful  surgical  operations.  He  is  a 
cautious,  expert  operator.  I.ike  most  English  surgeons,  he 
combines  asepsis  Avith  antisepsis.  As  an  irrigation  fluid  a 
solution  of  bichlorid  of  mercury,  1 :  10,000,  is  employed.  Xo 
gloves  are  used.  After  thorough  cleansing  of  the  hands  and 
field  of  operation  with  warm  water  and  soap,  turpentine  and 
bichlorid  solutions  follow  as  chemical  disinfectants.  Chloro- 
form is  vised  as  an  anesthetic.  He  has  never  vised  spinal  anes- 
thesia, and  is  averse  to  this  procedure,  as  he  considers  it  more 
dangerous  than  the  administration  of  anesthetics  by  inhalation. 
As  a  dressing  moist  cyanid  of  mercury  gauze  is  given  the 
preference  over  dry  antiseptic  dressing  material. 

I  had  an  opportunity  to  witness  two  of  his  operations  at  the 
University  College  Hospital. 

Case  I. — HartJeii-Kraase  operation  for  neuralgia  of  the 
trigeminus.  The  patient  was  a  man  advanced  in  years,  who  had 
suffered  for  a  long  time  from  excruciating  pain  in  the  course 
of  the  first  and  second  branches  of  the  trifacial  nerve.  Medical 
treatment  afforded  no  pernvanent  relief.  His  general  health 
Avas  not  seriously  impaired.  The  entire  scalp  was  shaved  and 
tlioroughly  prepared  l)y  scrubbing  with  hot  "water  and  soap, 
followed  by  turpentine,  and  after  removing  the  turpentine 
with  a  similar  scrubbing  the  surface  was  washed  and  scrul)bed 
repeatedly  with  a  1 :  500  solution  of  bichlorid  of  mercury.  After 
the  patient  was  fully  under  the  influence  of  chloroform  the 
temporal  region  was  freely  exposed  by  making  a  horseshoe- 
shaped  incision,  with  the  base  directed  downward,  and  l)y 
reflecting  two  flaps,  the  first  one  including  the  skin  and  the 
deep  one  ail  of  the  soft  structures  down  to  the  bone.  The  skull 
was  opened  by  removing  a  disc  of  bone  with  a  large  trephine, 
tlie  opening  was  then  enlarged  in  tlie  direction  of  the  base  of 
the  skull  with  strong  bone-cutting  forceps.  The  sharp-pointed 
triangular  blades  manipulated  by  the  expert  operator  accom- 
plished the  task  quickly  and  well.  With  the  operator's  dural 
reflector  the  envelopes  of  the  brain  were  carefully  separated 
over  the  extent  of  the  cranial  resection.  The  size  of  the  skull 
defect  before  the  intracranial  operation  was  commenced 
amounted  to  at  least  o  inches  in  the  transverse  and  2.^  inches  in 


the  vertical  diameter.  It  was  in  the  exposure  aud  excision  of 
the  gasserian  ganglion  that  the  great  skill  of  the  operator 
became  most  apparent.  With  a  broad  retractor  of  silver  the 
brain  and  its  envelopes  were  lifted  away  from  the  base  of  the 
skull,  which  was  followed  largely  by  the  use  of  dull  instru- 
ments uutil  the  ganglion  was  reached.  The  isolation  of  the 
ganglion  proved  to  be  the  most  difficult  part  of  the  operation. 
This  was  finally  accomplished  by  the  cautious  use  of  a  very 
small  scalpel  and  the  dural  reflector.  Capillary  and  venous 
hemorrhage  was  quite  free  and  was  kept  under  control  by 
making  compression  with  a  small  gauze  sponge  held  in  the 
grasp  of  a  forceps. 

The  ganglion  was  excised  with  as  much  of  the  proximal 
side  of  the  nerves  as  could  be  reached  with  safety.  As  some 
hemorrhage  continued,  the  space  occupied  by  the  excised  gang- 
lion was  packed  with  a  strip  of  gauze  which  was  brought  out 
at  one  of  the  angles  of  the  wound.  The  two  flaps  were  sutured 
separately  with  fine  silkwormgut.  This  is  at  present  Hors- 
ley's  favorite  suture  and  ligature  material.  Catgut  is  seldom 
eiiiployed  in  his  practice.  A  large,  moist  compress  of  cyanid 
of  mercury  gauze  constituted  the  dressing.  The  next  day  the 
patient  stated  that  he  was  free  from  pain.  The  gauze  tampon 
was  removed  and  a  similar  dressing  applied. 

Professor  Horsley  has  performed  this  operation  Go  times 
with  four  deaths.  In  the  patients  that  recovered  the  result  was 
satisfactory.  As  a  precaution  against  ophthalmic  complica- 
tions, the  eyelids  are  sutured  together  with  three  or  four  silk- 
wormgut sutures,  which  are  not  removed  for  three  or  four 
days. 

Case  II. — Retnovo,!  of  a  large  sarcoma  of  the  cerebellum.  In 
this  case  the  diagnostic  acuity  of  Professor  Horsley  was  fully 
confirmed  by  the  findings  revealed  during  the  operation.  A 
little  boy,  about  6  years  of  age,  had  been  suffering  for  several 
months  with  symptoms  which  pointed  to  the  cerebellum  as 
the  probable  seat  of  the  disease.  Among  the  prominent  symp- 
toms were  hemiparesis  in  the  right  side,  the  characteristic 
pupillary  changes  and  pain  in  the  occipital  region  with  moder- 
ate retraction  and  fixation  of  the  head.  From  these  and  other 
minor  symptoms  the  conclusion  was  reached  that  the  tumor 
was  located  in  the  cerebellum  on  the  right  side.  The  same 
preparations  were  made  as  in  the  foregoing  case.  The  patient's 
head  and  chest  were  slightly  elevated  and  turned  well  toward 
the  left  side.  The  occipital  bone  on  the  right  side  was  exposed 
by  reflecting  a  slightly  oval  flap  with  the  convexity  upward. 
Somewhat  profuse  hemorrhage  from  several  large  openings  in 
the  bone  occurred,  and  was  promptly  checked  by  rubbing  into 
the  bleeding  places  aseptic  wax.  From  the  promptness  with 
which  hemorrhage  was  arrested  from  this  source  it  was  evident 
that  this  material  is  of  great  value  in  arresting  hemorrhage 
from  bone.  With  cutting  forceps,  an  oval  opening  was  made  in 
the  occipital  bone,  about  two  by  three  inches,  with  the  long 
diameter  in  the  transverse  direction.  The  pulseless  dura  at 
once  bulged  into  the  opening.  Between  two  delicate,  grasping 
forceps  the  dura  was  nicked,  when  a  small  amount  of  cerebro- 
spinal fluid  escaped.  A  small,  grooved  director  was  inserted 
into  the  slit,  and  upon  it  the  dura  was  incised  in  a  vertical 
direction  to  the  extent  of  about  two  inches.    The  brain  now  pro- 


traded  into  thedural  opening.  With  a  probe  the  operator  tore 
a  small  opening  in  the  center  of  the  protruding  mass,  when  iu 
consequence  of  the  intense  intracranial  pressure  the  rent  greatly 
increased  in  size,  and  a  large  tumor  made  its  appearance  in  the 
tear  of  the  mantle  of  brain-tissue  which  covered  it.  The  tvimor 
was  firmer  and  more  vascular  than  the  surrounding  brain- 
tissue.  The  operator  remarked  that  he  considered  it  dangerous 
to  complete  the  operation,  as  he  had  lost  some  cases  from  cerebral 
edema  which  followed  the  immediate  removal  of  large  tumors 
of  the  brain.  The  wound  was  drained  with  gauze  and  sutured. 
The  dressing  consisted  of  a  large,  moist  compress  of  cyanid  of 
mercury  gauze.  The  child  showed  no  untoward  symptoms  dur- 
ing or  after  the  operation.  The  next  day  the  stitches  were 
removed,  the  skin-flap  reflected  and  the  tumor,  nearly  the  size 
of  a  hen's  egg,  was  found  on  the  surface  of  the  cerebellum,  and 
was  removed  without  the  slightest  difficulty.  The  intracranial 
pressure  had  effected  almost  complete  spontaneous  enucleation. 

The  idea  of  removing  large  tumors  of  the  brain  in  two 
stages  is  a  most  excellent  one,  and  this  method  will  undoubtedly 
be  the  means  of  materially  reducing  the  mortality  of  such 
operations.  Professor  Horsley  is  a  brilliant  scientist  and  a 
remarkable  surgeon,  and  when  the  King  knighted  him  he  per- 
formed an  act  which  met  a  hearty  approval  of  the  profession 
throughout  England. 

Two  Cases  of  Hysterectomy  for  Nontnalignant  Disease  of  the 
Uterus  by  Professor  W.  Japp  Sinclair. — During  my  attendance 
on  the  meetings  of  the  British  Medical  Association  I  had  the 
pleasure  of  witnessing  the  surgical  technic  of  Professor  W, 
Japp  Sinclair,  of  Owen  College,  Manchester.  As  an  eminent 
author  and  successful  clinical  teacher  he  is  well  known  in  the 
medical  world.  He  is  a  sturdy  hardworking  Scotchman,  a 
graduate  of  the  University  of  Aberdeen,  and  has  taught  obstet- 
rics and  gynecology  in  Owen  College  for  12  years.  By  ability 
and  hard  work  he  has  come  in  possession  of  a  large  and 
lucrative  private  practice.  He  is  a  firm  believer  in  asepsis  in 
surgery,  but  his  methods  in  accomplishing  the  desired  object 
are  of  the  simplest  kind.  In  his  hospital  work  two  assistants 
and  four  trained  female  nurses  render  the  necessary  assistance. 
He  is  a  bold  and  yet  a  conservative  operator.  When  he  sees  the 
indications  clear  for  an  operation  he  proceeds  without  hesitation 
and  performs  it  on  plans  well  mapped  out.  He  has  performed 
cesarean  section  18  times  and  saved  1()  mothers  and  their  chil- 
dren. In  one  of  the  two  fatal  cases  death  ensued  from  remote 
causes.  His  address  on  obstetrics  before  the  British  Medical 
Association  was  a  scholarly  product  full  of  good  sound  teaching 
and  was  highly  appreciated  by  his  large  and  attentive  audience. 
He  is  a  deep  thinker  and  a  fluent  speaker.  He  is  a  strong  advo- 
cate of  Schuchardt's  method  of  vaginal  hysterectomy.  The 
operation  is  described  as  follows  by  Schuchardt,  and  quoted  Ity 
Sinclair : 


While  the  perfected  vaginal  method  of  extirpation  of 
the  uterus  is  characterized  by  careful  protection  of  the  vaginal 
canal  and  of  the  external  genital  organs  by  means  of  specula  in 
order  to  keep  the  passage  to  the  portio  open,  etc.,  the  first  object 
of  the  paravaginal  method  is  to  obtain  free  access,  consistently 
Avith  surgical  principles,  to  the  diseased  organs.  Xo  attention 
is  paid  to  the  conventional  sparing  of  the  external  genitals ;  the 
left  labium  is  completely  split,  and  with  it  the  whole  vaginal 
tube,  with  the  vaginal  vault,  the  paravaginal  and  pararectal 
tissues,  the  levator  ani  and  coccygeal  muscles,  the  cellular 
tissue  of  the  ischiorectal  fossa,  as  well  as  the  skin  of  the  peri- 
neum and  of  the  lateral  anal  region  down  to  the  sacrum. 
Incisions  hitherto  employed  produced  only  a  dilation  of  the 
lower  portion  of  the  vagina,  the  paravaginal  incision  causes  a 
complete  gaping  of  the  vagina  and  vaginal  vault.  The  para- 
vaginal incision  begins  on  the  left  labium,  and  divides  the 
vaginal  wall  on  the  left  side,  but  in  its  deeper  parts  it  is  essen- 
tially a  median  incision.  Superficially  the  wound  is  situated  to 
the  left  only  so  far  that  the  rectum  and  sphincter  ani  are  not 
injured.  The  skin  incision  is  situated  in  the  vicinity  of  the 
anas,  distant  only  about  a  finger's  breadth  from  it;  it  then 
turns  round  it  in  a  circle  behind  the  anus  to  tbe  middle  line.  In 
this  essentially  median  position  of  the  wound,  which  yet  permits 
it  to  be  deepened  as  far  as  to  the  ligamentum  sacro-spinosum 
if  necessary,  lies  the  peculiarity  and  the  chief  advantage 
of  the  paravaginal  incision.  .  .  .  If  the  paravaginal  incision 
is  ettected  in  the  manner  described,  then  the  parametrium  on 
both  sides  becomes  equally  accessible  and  a  second  incision  on 
the  right  side  is  unnecessary.  .  .  .  Only  when  there  is 
occasion  to  remove  a  portion  of  cancerous  rectum  with  the 
cancerous  vaginal  wall  does  an  incision  on  the  right  side 
become  necessary.  The  two  incisions  then  enclose  between 
them  the  diseased  portion  of  the  vagina  and  rectum,  and  meet 
behind  in  the  middle  line. 

Sinclair  has  performed  the  paravaginal  operation  14  times 
and  is  well  pleased  with  the  technic  of  the  operation  and  its 
results. 

Case  I. — The  patient  was  a  nullipara,  aged  35,  married,  but 
uever  pregnant.  For  three  years  she  has  suffered  from  menor- 
rhagia  and  pelvic  distress,  has  not  been  benefited  by  repeated 
curetings  and  general  treatment.  Uterus  was  enlarged,  para- 
metrium free.  The  operation  was  performed  in  the  manner 
described.  The  slitting  of  the  vulva  and  vaginal  wall  gave 
rise  to  free  hemorrhage,  which  was  at  once  arrested  by  the 
application  of  hemostatic  forceps  and  ligation.  The  deep,  gap- 
ing wound  rendered  the  access  to  the  uterus  and  adnexa  very 
easy.  The  operation  was  completed  in  less  than  an  hour,  as 
the  uterus  was  movable  and  yielded  readily  to  traction.  The 
operator's  large  curved  needle  was  used  in  applying  the  deep 
silk  ligatures.  The  vaginal  vault  was  sutured  and  the  culde- 
sac  drained  with  a  soft  rubber  tube,  to  which  a  strong  silk  liga- 
ture was  tied  for  its  easy  extraction.  The  vaginal  cut  and  the 
ischiorectal  wound  were  sutured  likewise  with  silk.  The 
vagina  was  lightly  tamponed  with  iodoform  gauze  and  iodo- 
form was  freely  sprinkled  between  the  layers  of  the  gauze. 
Retractors  were  only  used  in  lifting  the  anterior  vaginal  wall 
forward.  The  extirpated  uterus  was  enlarged,  succulent,  and 
the  mucosa  granular. 


10 


Case  II. — The  patient  was  a  married  wouiau,  aged  52,  who 
had  given  birth  to  several  children  and  had  reached  her  meno- 
pause at  the  age  of  50.  Recently  she  has  suffered  repeated  uter- 
ine hemorrhage  and  profuse  leukorrheal  discharge.  Vaginal 
examination  revealed  a  fixed  uterus  with  a  hard  mass  on  the 
right  side.  The  suspicion  of  malignancy  was  a  strong  one  and 
hysterectomy  was  recommended  and  eagerly  accepted  by  the 
patient.  In  this  case  the  operation  proved  a  very  difficult  one, 
owing  to  the  numerous  firm  parametric  adhesions,  and  the 
paravaginal  incisions  did  not  give  any  too  much  room  for  the 
extirpation  of  the  uterus.  The  right  ovary  was  cystic  and 
embedded  in  a  mass  of  adhesions.  The  operation  required 
much  patience  and  perseverance,  but  was  completed  without 
any  mishap.  The  wound  was  closed  in  a  similar  manner  as  in 
the  first  case. 

The  paravaginal  operation  is  to  be  recommened,  particu- 
larly in  cases  in  which  the  vagina  is  narrow  and  unyielding, 
and  when  the  uterus  is  fixed  in  a  high  position,  and  finally 
when  carcinoma  has  involved  the  tissues  around  the  vaginal 
portion  of  the  uterus. 

London,  August  2. 


[Reprinted  from  A^nerican  Medicine,  Vol.  IV,  No.  20,  pages  786-788, 
November  15,  1902.] 


PROFESSOR  JOHN  BERG'S  SURGICAL  CLINIC. 

BY 

NICHOLAS  SENN,  M.D., 
of  Chicago. 

Sweden  has  three  universities,  located  in  the  cities  of  Stock- 
holm, XJpsala  and  Lund ;  each  of  these  universities  has  a 
medical  department.  The  largest  medical  school  is  the  Caroline 
Medico-Chirurgical  Institute,  connected  with  the  University  of 
Stockholm.  This  institution  has  an  attendance  of  from  250  to 
300  students,  and  graduates  from  20  to  50  every  year.  The 
medical  course  extends  over  seven  to  nine  years,  according  to 
the  natural  ability  and  application  of  the  student.  The  long 
course  of  study,  the  small  classes,  the  abundance  of  clinical 
material  and  the  well-equipped  laboratories  afford  the  students 
all  necessary  facilities  to  obtain  a  thorough  theoretic  and  prac- 
tical knowledge  of  medicine  and  surgery. 

For  the  last  15  years  women  have  been  admitted  to  the 
medical  school,  and  have  made  an  enviable  record  as  earnest, 
diligent  students.  Professor  Berg  informed  me  that  they  rank 
among  the  first  in  the  different  classes,  more  especially  in  the 
theoretic  courses.  In  the  audience  of  about  30  in  the  surgical 
clinic  I  attended  there  were  three  women,  and  I  noticed  how 
intently  they  followed  the  remarks  of  the  lecturer  and  every 
step  of  the  operative  work,  and  they  were  the  last  to  leave  the 
clinical  theater.  There  are  now  25  female  physicians  in  Stock- 
holm engaged  in  practising  their  profession  and  in  honorable 
contest  with  their  more  numerous  male  competitors.  So  long 
as  women  insist  on  studying  and  practising  medicine  they 
should  be  given  the  best  opportunities  to  satisfy  their  desire 
and  ambition,  and  this  can  only  be  done  by  coordinate  educa- 
tion. Female  physicians  have  secured  a  permanent  foothold  in 
the  medical  profession,  but  it  would  be  to  their  interest  and 
advantage  if  they  would  devote  their  time  and  talents  to  gyne- 
cology, obstetrics,  diseases  of  children,  diseases  of  the  eye,  ear, 
nose  and  throat,  and  dentistry.  Nature  has  endowed  them  with 
qualities  well  calculated  to  practise  these  specialties  with  sue- 


Professor  John  Berg. 


cess  and  a  good  prospect  of  an  independent,  comfortable  exist- 
ence.   The  clinical  teaching  of  the  Caroline  Medico-Chirurgical 
Institute  is  conducted  in  the  Serafrim 
Hospital. 

Serafrim  Hospital.— This  institu- 
tion is  supported  by  the  government, 
and  has  a  capacity  of  400  beds.  The 
members  of  the  faculty  compose  the 
medical  staff.  The  surgical  depart- 
ment has  140  beds  and  is  located  in  the 
old  part  of  the  building.  The  surgical 
clinics  are  conducted  by  Professor 
John  Berg  and  Professor  J.  H.  Aker- 
man.  Professor  Berg  is  the  head  pro- 
fessor. The  surgical  cases  of  the  large 
Poliklinik  are  in  charge  of  the  same 
men.  The  clinical  service  alternates 
between  the  two  professors  every 
four  months.  The  clinical  amphithe- 
ater can  seat  about  50  students.  Most 
of  the  major  operations  are  per- 
formed in  an  adjoining  operating-room,  to  which  only  a  few 
students,  wearing  linen  gowns,  are  admitted.  Both  operating- 
rooms  are  supplied  with  all  necessary  instruments  and  facilities 
for  asepsis.  In  the  operating-rooms  there  is  no  unnecessary 
display  in  making  preparations  for  an  operation.  No  gloves  and 
no  caps.  The  fact  is  fully  recognized  here  that  clean  hands, 
sterile  instruments,  ligature,  suture  and  dressing  material  and 
a  carefully  disinfected  operative  field  are  the  essential  pre- 
requisites to  procure  asepsis.  Hand  and  surface  disinfection 
are  made  by  scrubbing  for  a  sufficient  length  of  time  wnth  warm 
water  and  potash  soap,  followed  by  1:1,000  bichlorid  of  mer- 
cury solution  and  a  2%  solution  of  creolin.  Chloroform  by  the 
drop  method  is  the  favorite  anesthetic,  but  ether  is  used  in 
cases  in  which  it  is  deemed  safer  than  chloroform.  Two  house 
surgeons  assist  the  operator.  A  trained  female  nurse  handles 
the  instruments,  ligatures  and  needles,  and  a  second  one  takes 
care  of  the  gauze,  sponges  and  dressing  material.  Catgut  is  pre- 
pared according  to  von  Bergmann's  directions,  and  instruments 
and  silk  are  sterilized  by  boiling.  In  the  abdominal  cavity 
silk  is  used  almost  exclusively,  catgut  for  buried  sutures.  In 
the  clinical  amphitheater  much  of  the  time  is  spent  in  diagnosis 
instruction,  the  operative  work  being  limited  to  emergency 
cases,  minor  operations  and  infected  cases. 

Professor  Berg,  the  successor  to  the  late  Professor  Ross- 
ander,  is  the  head  professor  of  surgery  and  senior  sur- 
geon to  the  Serafrim  Hospital.   He  is  in  the  prime  of  life,  above 


average  height,  with  a  noble,  dignified  bearing  that  at  once 
betokens  the  gentleman  and  scholar.  Modesty  is  one  of  the 
most  reliable  indications  of  genuine  greatness,  and  this  is  one  of 
the  many  virtues  that  characterize  the  life  and  work  of  Profes- 
sor Berg.  He  is  a  great  favorite  among  his  students  and  a 
friend  to  his  patients.  He  is  careful  in  the  selection  of  his  cases 
for  operation,  and  his  clinical  teaching  is  noted  for  the  con- 
servative spirit  which  predominates,  something  which  cannot 
be  said  of  all  of  the  clinics  on  the  Continent.  He  recognizes  the 
limits  of  the  art  of  surgery,  and  takes  great  pains  in  emphasizing 
them  in  his  teachings.  He  is  a  fluent  and  forcible  speaker  who 
has  no  difficulty  in  commanding  the  attention  of  his  class  and 
of  imparting  his  earnestness  and  enthusiasm  to  every  one  of 
his  listeners.  A  very  important  feature  of  his  clinic  is  the 
assigning  of  a  case  to  one  of  the  candidates  for  graduation. 
The  student  must  write  a  full  history  of  the  case,  which  is  read 
by  the  professor  when  the  case  is  presented,  and  he  must  be 
prepared  to  defend  his  diagnosis,  witness  the  operation  and 
visit  and  report  upon  the  progress  of  the  case  daily  thereafter. 
This  kind  of  clinical  instruction  is  a  method  of  teaching  best 
calculated  to  make  the  student  a  good  diagnostician  and  a 
thinking,  safe  practitioner.  Sweden  has  an  excellent  system  of 
preparing  young  physicians  for  hospital  work.  Throughout 
the  kingdom  hospitals  are  being  built  in  all  of  the  larger 
villages,  but  restrictions  are  placed  on  the  candidates  who 
make  application  for  the  medical  service.  It  is  an  inflexible 
rule  that  such  candidates  must  present  a  certificate  showing 
that  they  have  served  satisfactorily  as  an  assistant  in  one  of  the 
large  clinics  for  a  period  of  at  least  three  years.  This  is  a  most 
excellent  plan,  as  it  assures  for  the  most  remote  parts  of  the 
country  excellent  medical  and  surgical  skill. 

Limitation  of  hospital  practice  is  surely  needed  in  our 
country,  and  it  would  be  well  for  our  profession,  and  still 
better  for  serious  cases  remote  from  medical  centers  if  the 
same  regulations  could  be  enforced  which  have  been  in  such 
successful  operation  in  Sweden  for  a  number  of  years. 

Operations.— Frofessor  Berg  is  a  very  careful  and  skilful 
operator.  He  makes  no  attempt  at  display  of  his  manual  dex- 
terity. He  operates  upon  his  clinical  cases  with  the  same  care 
and  consideration  as  upon  his  private  patients.  He  never  for- 
gets that  he  is  not  only  an  operator  but  also  a  teacher.  He  is 
keenly  conscious  of  his  responsibilities  to  his  students,  who, 
as  is  generally  the  case,  will  imitate  the  example  of  their  teacher. 
He  teaches  his  students  not  only  how  to  operate  but  also  where 
and  when  not  to  operate.  His  clinical  lectures  are  devoted 
largely  to  diagnosis  and  a  comprehensive  study  of  the  patho- 
logic conditions  presented  by  the  case  under  consideration. 


The  furor  operativus  has  found  no  foothold  in  his  clinic.  He 
is  familiar  with  what  is  going  on  in  the  surgical  world  but  is 
slow  in  adopting  new  doubtful  procedures.  He  regards  spinal 
anesthesia  with  mistrust  and  has  never  given  it  a  trial.  He  is 
not  willing  to  abandon  well-tried  reliable  methods  for  innova- 
tions of  doubtful  value  simply  because  they  are  something  new. 
On  the  day  of  iny  visit  to  his  clinic  two  very  rare  and  extremely 
interesting  cases  furnished  the  text  for  his  clinical  lecture. 

Case  1.— Retention  cyst  {?)  of  the  frontal  sinus ;  operation. 
The  patient  was  a  man,  aged  25,  the  subject  of  an  orbital  swell- 
ing. The  swelling  involved  the  right  orbital  cavity  and  was 
first  noticed  seven  years  ago.  There  was  no  pain  nor  tender- 
ness. There  was  slight  exophthalmos  and  outward  deviation  of 
the  eye.  Nasal  cavities  w^ere  normal.  Distinct  fluctuation 
elicited  on  palpation  led  to  the  information  that  the  swelling 
was  in  part  covered  by  a  thin  plate  of  bone.  The  swelling 
occupied  the  inner  upper  quadrant  of  the  orbital  cavity. 
Eyesight  was  unimpaired.  The  case  was  thoroughly  dis- 
cussed from  a  diagnostic  point  of  view.  The  obscurity  of 
the  nature  of  the  swelling  was  emphasized.  Osteoma  of  the 
orbit,  dermoid  cyst,  inflammatory  diseases  of  the  frontal  sinus 
and  ethmoidal  cells  and  malignant  tumors  were  all  mentioned, 
but  the  final  diagnosis  was  left  for  the  operation  to  reveal.  The 
patient  was  prepared,  anesthetized  and  the  operation  com- 
menced by  making  an  incision  along  the  orbital  arch  down  to 
the  frontal  bone.  With  an  elevator  the  periosteum  was  reflected 
in  the  direction  of  the  swelling.  As  soon  as  the  orbital  cavity 
was  reached  a  yellowish  white  gelatinous  material  escaped  and 
the  opening  led  into  a  large  cavity— the  distended  frontal  sinus. 
This  cavity  contained  at  least  three  ounces  of  the  same  kind  of 
material.  The  communicating  opening  between  the  frontal 
sinus  and  the  nasal  cavity  was  found  without  any  particular 
difficulty  with  the  probe.  With  a  chisel  and  hammer  part  of 
the  orbital  margin  was  removed  to  aff'ord  freer  access  to  the 
cavity  which  was  then  thoroughly  cleansed  of  its  contents  and  . 
the  lining  membrane  excised  with  forceps  and  curved  scissors. 
The  opening  between  the  sinus  and  nasal  cavity  was  enlarged 
until  the  tip  of  the  index  finger  could  be  inserted.  The  cavity 
was  then  packed  with  a  Mikulicz  drain  and  the  external  inci- 
sion reduced  in  length  by  suturing  with  silk.  A  small 
absorbent  dressing  finished  the  operation.  The  nature  of  the 
cyst  contents,  the  absence  of  all  inflammatory  indications,  leave 
but  little  doubt  that  the  case  was  one  of  retention  cyst  or 
myxoma  of  the  frontal  sinus. 

Case  II. —  Ulcer  of  duodenum;  gastroenterostomy.  The 
patient  was  a  woman  of  40,  who  for  20  years  had  suffered  from 
symptoms  indicative  of  a  faulty  digestion.  Pain  and  distress 
was  not  aggravated  by  the  quantity  and  quality  of  the  food. 
There  were  repeated  attacks  of  hematemesis  and  discharge  of 
altered  blood  through  the  intestinal  canal.  An  enlargement 
could  be  palpated  in  the  region  of  the  pylorus.  Patient  was 
somewhat  emaciated  and  anemic.  Heart's  action  was  weak, 
circulation  feeble.  Probable  diagnosis  of  ulcer  of  duodenum 
was  made  by  exclusion.  Owing  to  the  weak  action  of  the 
heart  ether  was  used  as  an  anesthetic.  The  skin  in  the  line  of 
abdominal  incision  was  infiltrated  with  Schleich's  solution  for 
the  purpose  of  reducing  the  amount  of  the  anesthetic  to  a  min- 


imuni  and  to  shorten  the  time  required  for  operation.  The 
operator  decided  to  perform  a  gastroenterostomy  with  a  view  of 
securing  rest  for  the  ulcerated  part  of  the  intestinal  tract  by 
excluding  it  from  the  active  process  of  digestion.  A  median 
incision  was  made  extending  from  the  tip  of  the  ensiform  car- 
tilage to  the  umbilicus.  The  stomach  and  duodenum  presented 
no  visible  or  palpable  evidences  of  disease.  From  this  it  was 
evident  that  the  ulcer  of  the  duodenum,  which  was  unquestion- 
ably present,  had  not  penetrated  deep  enough  to  involve  the 
peritoneal  coat.  The  head  of  the  pancreas  was  enlarged,  but 
retained  its  form  and  consistency.  Professor  Berg  is  in  favor 
of  posterior  gastroenterostomy,  but  in  this  case  the  anterior 
operation  had  to  be  performed  because  the  mesocolon  was  too 
short  for  the  posterior.  The  anastomosis  was  made  near  the 
pylorus  and  the  large  curvature  of  the  stomach.  Doyen's  long 
clamps  for  the  stomach  and  intestinal  clamps  for  the  jejunum 
were  used  to  exclude  stomach  and  intestinal  contents  from  the 
seat  of  operation.  A  loop  of  the  upper  part  of  the  jejunum 
was  sutured  with  silk  to  the  anterior  surface  of  the  stomach  in 
its  long  axis  at  the  point  indicated  to  the  extent  of  three  inches. 
The  peritoneal  coat  of  the  stomach  and  duodenum  was  incised 
two  lines  from  the  row  of  Lembert  stitches,  over  which  another 
row  of  serous  stitches  was  applied.  The  visceral  wound  on 
each  side  was  next  completed,  the  mucous  membrane  all 
around  united,  and  the  anterior  stitches  buried  under  two  rows 
of  Lembert  stitches.  The  sewing  was  done  exclusively  by  con- 
tinuous silk  sutures.  A  flap  of  the  omentum  was  now  drawn 
from  the  pyloric  side  and  laid  over  the  line  of  suturing 
anteriorly  and  fixed  in  place  with  three  serous  sutures.  The 
abdominal  incision  was  closed  with  three  rows  of  silk  sutures. 
The  wound  was  covered  with  a  small  absorbent  dressing.  The 
whole  operation  was  completed  in  less  than  an  hour  and  was 
executed  with  a  delicacy  and  skill  as  pleasing  to  the  audience 
as  it  must  have  been  satisfactory  to  the  operator. 

Other  Stockholm  Hospitals.— ^iodkhoVm.  has  made  ample 
provision  for  its  sick  poor.  It  is  well  supplied  with  well-man- 
aged hospitals  and  charitable  institutions  for  the  insane,  the 
aged,  the  poor,  and  the  orphans. 

Sophia  Hospital.— This  magnificent  hospital,  with  its  park- 
like grounds,  is  the  creation  of  the  Queen  of  Sweden.  It  con- 
tains 80  beds  and  is  managed  by  the  Sisters  of  Sophia.  The 
material  for  this  order  of  Sisters  is  selected  from  the  best  families 
in  Sweden.  The  Sisters  are  in  training  in  this,  the  mother  house, 
for  2^  years,  and  after  their  graduation  they  are  expected  to 
serve  the  rich  and  the  poor  without  expectation  of  a  financial 
reward,  as  their  earnings  go  into  the  general  fund  of  the  sister- 
hood. The  nursing  in  this  hospital  is  therefore  of  the  highest 
order.  The  wards  and  private  rooms  are  elegantly  furnished. 
The  two  new  operating-rooms  are  models  of  their  kind  and  a 
glance  at  them  would  inspire  every  surgeon  with  confidence  so 
far  as  the  facilities  for  aseptic  precautions  are  concerned.  One 
of  the  features  of  these  rooms  is  the  electric  lighting.  The 
electric  lamps  over  the  operating  table  are  covered  with  glass 
and  a  convex  glass  between  the  lamps  directs  the  rays  of  light 


6 

m  such  a  manner  that  no  shadows  are  cast  upon  the  field  of 
operation.  For  the  best  private  rooms  a  charge  of  seven  kronen 
is  made.  The  hospital  expenses  of  the  poor  are  often  paid  by 
the  congregations  to  which  they  belong.  The  Queen  is  a  liberal 
contributor  to  the  annual  expenses  and  is  a  frequent  visitor  at 
the  hospital. 

Crown  Princess  Louisa  Hospital.— This  hospital  is  devoted 
to  the  care  of  sick  children  and  is  under  the  patronage  of  Crown 
Princess  Louisa.  The  buildings  are  two  and  three  stories  high 
and  are  surrounded  by  an  attractive  flower  garden.  It  has  a 
capacity  of  120  beds.  The  medical  side  is  in  charge  of  Prof. 
Jonas  Waern,  the  surgical  department  is  presided  over  by 
Docent  Dr.  Bjorn  Floderus,  and  Dr.  Oscar  Gibson  is  chief  of  the 
polyclinic.  The  operating-room  is  small,  but  is  well  supplied 
with  instruments  and  all  facilities  for  aseptic  work.  The 
expenses  for  indigent  children  are  paid  by  the  districts  from 
which  they  are  sent.  Last  year  a  bazaar  under  the  patronage 
of  Princess  Louisa  netted  86,068  kronen.  Of  this  amount  James 
Carnegie  contributed  20,000  kronen.  The  receipts  from  pay 
patients  during  the  same  time  amounted  to  6,547.25  kronen, 
while  the  total  running  expenses  for  the  year  reached  the  sum 
of  110,434  kronen.  Last  year  244  operations  were  performed, 
with  234  recoveries,  five  improvements,  and  only  five  deaths,  a 
good  record  considering  that  many  of  the  operations  were  per- 
formed for  far  advanced  tuberculous  affections  of  joints,  bones, 
lymphatic  glands,  and  skin.  In  the  polyclinic  435  minor  opera- 
tions were  made  with  no  mortality. 

Deaconess  Hospital.— This  hospital,  with  80  beds  and  a 
home  for  the  aged,  is  beautifully  located  on  a  high  embank- 
ment facing  the  harbor  of  Stockholm.  It  is  in  charge  of  an 
order  of  Sisters  and  has  an  excellent  training  school,  where 
Sisters  are  prepared  for  their  life  work.  Dr.  Hugo  Toll,  who 
practised  his  profession  for  a  number  of  years  in  Minneapolis, 
Minn.,  is  the  surgeon-in-chief.  His  skill  as  an  operator  is 
highly  appreciated  by  the  hospital  authorities,  the  Sisters  and 
his  patients.  He  keeps  pace  with  the  rapid  progress  of  surgery, 
and  his  results  would  compare  favorably  with  those  of  any 
other  hospital.  Space  does  not  permit  to  describe  the  remaining 
hospitals  of  Stockholm,  but  it  can  be  said  with  credit  to  this 
Venice  of  the  North  that  it  has  made  excellent  and  wise  pro- 
vision for  patients  of  means  as  well  as  its  deserving  sick  poor. 

Stockholm,  August  10. 


(Reprinted  from  American  Medicine,  Vol.  IV,  No.  24,  pages  942-946 
December  13,  1902.] 


PRESENT  SURGICAL  METHODS   IN  THE    GENERAL 
HOSPITAL  HAMBURG-EPPENDORF. 

BY 

NICHOLAS  SENN,  M.D., 
of  Chicago. 

The  new  Allgemeine  Krankenhaus  Hamburg-Eppendorf 
accommodates  2,000  patients.  It  is  built  on  the  barrack  plan, 
and  is  spread  out  over  several  acres  of  g^round.  The  different 
buildings  are  numbered  and  the  streets  and  sidewalks  inter- 
secting them  are  laid  otit  in  the  form  of  a  miniature  city.  All 
of  the  buildings  are  constructed  upon  modern  plans,  and  are 
heated  by  steam  and  lighted  by  electricity.  The  four  operating- 
rooms  which  are  in  use  at  the  present  time  are  furnished  with 
«very  possible  convenience  for  aseptic  work.  Many  of  the 
little  aids  to  perfect  aseptic  precautions  are  the  inventions  of 
Dr.  Kiimmell,  who  has  spent  much  time  and  thought  in  sim- 
plifying and  rendering  more  effective  the  aseptic  precautions 
now  in  general  use.  Among  these  are  the  ingenious  applica- 
tion of  a  rubber  cork  for  bottles  containing  saline  and  antiseptic 
solutions,  a  fountain  alcohol  dropper  worked  by  compressing 
a  rubber  bulb  with  the  foot,  and  bottles  in  which  catgut  and 
silk  are  preserved  for  immediate  use.  The  instrument  supply 
in  each  of  the  operating-rooms  is  complete  and  in  charge  of  a 
well-trained  orderly  (Oberwarter),  who  is  held  responsible  for 
their  perfect  and  sterile  condition  and  proper  arrangement  on 
the  instrument  table.  Two  house  surgeons  assist  the  operator 
and  a  third  administers  the  anesthetic,  which  at  present  consists 
of  a  definite  mixture  of  chloroform  and  oxygen  gas.  Two 
trained  female  nurses  attend  to  the  gauze,  sponges,  and  dress- 
ings. 

This  hospital  contains  a  larger  number  of  surgical  patients 
than  any  other  hospital  in  the  world,  the  number  ranging  from 
500  to  750.    It  is  a  great  pity  that  this  immense  material  cannot 


be  utilized  for  clinical  instruction  on  a  greater  scale.  Hamburg 
should  have  a  university,  and  the  general  hospital  is  the  proper 
place  for  the  medical  department.  There  are  some  indications 
that  this  desire  will  be  realized  in  the  near  future.  An  oper- 
ating-theater with  a  seating  capacity  for  120  is  now  in  process  of 
construction,  and  university  instruction  is  now  given  by  emi- 
nent scientists  in  nearly  all  studies  given  in  university  courses. 
These  lectures  are  given  gratuitously.  Hamburg  is  the  most 
beautiful  of  all  European  cities,  a  great  seaport  in  close  touch 
with  all  parts  of  the  world,  and  all  it  needs  to  make  it  an  ideal 
city  is  a  great  university.  The  creation  of  a  live,  efficient  med- 
ical school  would  meet  no  difficulties,  as  the  present  clinical  and 
teaching  force  would  constitute  a  strong  faculty,  and  the 
immense  clinical  and  anatomic  material,  with  the  existing 
laboratories  and  museums,  would  answer  all  the  immediate 
requirements  as  a  teaching  material.  The  surgical  department 
of  the  general  hospital  has  won  an  enviable  reputation 
throughout  the  entire  medical  world.  It  is  not  uncommon  to 
find  in  the  little  audience  of  six  to  twelve  which  gathers  around 
the  operating  tables  every  day,  eager  to  see  the  most  recent 
innovations  in  surgery  and  to  witness  the  most  difficult  things 
in  operative  skill,  clinical  teachers  from  as  many  medical 
schools  and  countries.  I  know  of  no  other  place  where  a  man 
can  see  and  learn  more  in  the  same  space  of  time.  The  only 
regret  of  the  visitor  is  that  he  cannot  witness  all  of  the  operations 
going  on  at  the  same  time.  He  is  never  idle.  When  an  opera- 
tion is  completed  all  he  has  to  do  is  to  step  into  the  next  room, 
where  another  operator  is  at  work,  and  when  he  has  finished 
the  visitor  can  retrace  his  steps  and  find  another  patient  is  on 
the  table  ready  for  operation. 

Surgical  Service.— ^iuQe  Schede  left  the  hospital  in  1893  to 
accept  the  professorship  at  Bonn  the  surgical  service  is 
divided  equally  between  Dr.  Hermann  Kiimmell,  first  chief 
surgeon,  and  Dr.  Sick,  second  chief  surgeon.  From  10  to  14 
new  cases  are  received  daily.  The  infected  ones  are  assigned 
at  once  to  the  wards  where  they  belong ;  all  other  patients  enter 
the  receiving  pavilion,  where  they  are  given  a  bath  and  are  fur- 
nished with  the  hospital  garb.  Dr.  Kiimmell  attends  to  the 
receiving  ward  four  days  in  the  week  and  Dr.  Sick  three  days, 
but  for  the  purpose  of  equalizing  the  material  all  children 
under  12  years  are  assigned  to  Dr.  Sick.  In  the  receiving-room 
the  patients  are  examined  and  after  the  diagnosis  is  made  are- 
sent  to  their  appropriate  wards.  In  this  way  the  clinical 
material  is  systematized  and  properly  distributed. 

Surgical  Work  of  Dr.  Eilnimell.—'' Yrsesente  segroto  Tac- 
eunt  colloquia,  Effugiat  visus  Decus  omnia  dominat  morbus." 
This  is  a  warning  printed  in  large  type  which  stares  the  visitor 


8 


Dr.  Hermann  Kiimmell. 


in  the  face  from  the  wall  he  is 
likely  to  face  in  every  operat- 
ing-room. Every  visitor  is  re- 
quested to  remove  his  coat  and 
wear  a  linen  gown.  Dr.  Kiim- 
mell was  well  prepared  for  the 
present  position  when  he  be- 
came the  succei?sor  to  Schede. 
His  scientific  investigations 
which  led  to  the  introduction 
of  bichlorid  of  mercury  as  an 
antiseptic  brought  him  at  once 
into  prominence.  His  clinical 
observations  on  intestinal  ob- 
struction and  appendicitis  are 
closely  interwoven  with  the 
progress  of  modern  surgery.  He  is  a  diligent  student  and  an 
enthusiastic,  deliberate  and  careful  operator.  He  is  not  what 
some  are  fond  of  being  called,  "a  lightning  operator,"  but  his 
vast  experience,  his  thorough  knowledge  of  anatomy,  and  his 
familiarity  with  the  changes  wrought  by  pathologic  processes 
place  him  in  a  position  to  proceed  with  his  work  without  hesi- 
tation. He  has  reached  the  age  of  greatest  usefulness  and  we 
may  look  to  him  with  confidence  for  many  scientific  and  clinical 
literary  productions,  the  fruit  of  his  labors  in  his  present  fertile 
clinical  field.  When  the  opportunity  presents  itself  he  will 
occupy  the  front  rank  as  a  clinical  teacher,  as  he  is  in  possession 
of  all  the  desirable  qualifications  for  such  a  position. 

Dr.  KiimmelVs  Methods  in  Abdominal  Operations. — There 
is  no  gynecologic  department  in  the  Hamburg  General  Hos- 
pital. Gynecology  is  here  a  part  of  general  surgery.  From  one 
to  four  abdominal  and  pelvic  operations  are  made  here  almost 
every  day.  Dr.  Kiimmell  has  contributed  much  by  writing 
and  example  to  the  perfection  of  abdominal  surgery.  He  can 
speak  on  this  subject  with  authority.  I  will  give  a  brief  outline 
of  the  methods  now  in  use  as  practised  by  him  and  his  colleague, 
Dr.  Sick. 

Preparation  of  Patient.— In  very  weak  patients  a  roborant 
and  nutritive  course  of  treatment  is  resorted  to  for  a  few  days 
before  the  operation.  Subcutaneous  injections  of  sterilized 
olive  oil  (Leube),  nutrient  enemas  and  intravenous  infusion  of 
physiologic  solutions  of  salt  have  been  found  most  useful  in 
increasing  the  resisting  power  of  the  patient  sufficiently  to  war- 
rant surgical  interference.  Two  quarts  of  saline  solution  are 
infused  twice  or  thrice  a  day  for  several  days  preceding  opera- 
tion. The  bowels  are  moved  thoroughly  the  day  before  the 
operation.    Prolonged  or  repeated  catharsis  is  warned  against 


in  most  emphatic  terms.  If  the  stomach  is  not  empty  it  is 
evacuated  by  siphonage  before  the  anesthetic  is  commenced .  On 
the  evening  before  the  operation  the  abdomen  is  thoroughly 
cleansed  with  sulfuric  ether,  shaved  and  scrubbed  with  soap  in 
the  cleansing  bath.  The  abdomen  is  then  covered  with  a  com- 
press wrung  out  of  a  bichlorid  of  mercury  solution  1 :  2,000, 
which  is  kept  moist  by  applying  over  it  some  waterproof 
material. 

Anesthesia.— Fifteen  minutes  before  the  anesthetic  is  com- 
menced, 0.01  gram  morphia  with  atropin  is  injected  subcutane- 
ously.  Male  patients  addicted  to  the  use  of  spirits  are  given  a 
wineglassful  of  cognac. 

In  the  narcosis-room  absolute  quietness  is  enforced  ;  no  one 
but  the  anesthetizer  and  a  Sister  are  admitted.  Chloroform  is 
the  anesthetic  in  use,  ether  in  only  exceptional  cases  when  the 
patient  is  very  weak  or  the  subject  of  heart  disease,  or  finally  in 
continuing  the  chloroform  narcosis  in  operations  of  long  dura- 
tion. 

The  drop  method  was  employed  exclusively  until  the  intro- 
duction of  the  oxygen  (Wohlgemuth)  admixture.  The  apparatus 
now  in  use  registers  wath  accuracy  the  quantity  of  oxygen  and 
chloroform  inhaled.  A  deep  narcosis  is  essential  in  all  opera- 
tions in  the  Trendelenburg  position,  as  the  slightest  muscular 
contractions  force  the  intestines  forward  into  the  w^ound,  thus 
obscuring  the  pelvic  view.  Local  anesthesia  by  Schleich's 
infiltration  method  is  resorted  to  when  the  general xiondition  of 
the  patient  contraindicates  the  administration  of  a  general  anes- 
thetic. Spinal  anesthesia  was  tried  in  ten  cases,  but  the  results 
w^ere  such  that  it  has  been  permanently  abandoned. 

Disinfection  of  the  Patient. — After  the  patient  is  completely 
under  the  influence  of  the  anesthetic  the  disinfection  is  com- 
pleted before  he  is  transferred  to  the  operating  table.  After 
removal  of  the  sublimate  compress,  one  of  the  assistants,  prop- 
erly prepared,  scrubs  the  abdomen  wath  marbledustsoap  with  a 
bunch  of  sterilized  wood  fibers.  The  softened  epithelial  cells 
are  rubbed  off  so  far  as  this  can  be  done.  This  mechanic 
cleansing  is  regarded  as  the  most  important  part  of  the  entire 
process  of  surface  disinfection.  After  removal  of  the  soap  with 
a  sterile  towel  the  surface  is  scrubbed  with  alcohol,  applied 
W'ith  a  gauze  sponge,  followed  by  rubbing  wdth  ether.  The 
use  of  the  ether  is  continued  until  the  white  sponges 
are  no  longer  stained.  When  the  white  gauze  is  no  longer 
discolored  the  best  proof  is  furnished  that  the  mechanio 
cleansing  is  as  complete  as  it  can  be  made.  Alcohol  is 
then  used  again,  and  lastly  rubbing  off  with  a  bichlorid  solu- 
tion, 1 : 1,000,  completes  the  disinfection  of  the  field  of  operation. 


The  abdomen  is  then  covered  with  a  sterile  cloth  and  the 
patient  placed  upon  the  operating  table. 

Prepa7'ation  of  the  Surgeon  and  Assistants. — Contamination 
of  hands  with  septic  material  must  be  avoided  for  at  least  24 
hours  before  the  operation.  If  during  that  time  it  becomes 
necessary  to  operate  on  septic  cases,  rubber  gloves  must  be 
worn.  If  visits  to  the  postmortem-room  are  made,  a  change  of 
clothing  and  a  bath  are  insisted  upon.  The  operator  and  assist- 
ants wear  a  white  cap  to  avoid  the  entrance  into  the  abdominal 
cavity  of  hair  and  other  infectious  material,  should,  as  some- 
times happens,  their  heads  come  in  contact  during  the  opera- 
tion. Linen  gowns  are  worn  by  all  in  the  operating-room. 
Gloves,  face  and  head  masks  are  considered  superfluous  pre- 
cautions. 

Much  stress  is  placed  upon  the  importance  of  proper  care  of 
the  hands,  as  smooth  skin  can  be  more  easily  disinfected  than 
rough  skin.  Lanolin  and  glycerin  are  recommended.  The 
statement  is  made  and  emphasized  that  the  hands  with  smooth, 
healthy  skin,  after  a  thorough  mechanic  cleansing  are  practi- 
cally free  from  bacteria,  with  or  without  the  subsequent  use  of 
alcohol.  The  best  remedy  for  the  cleansing  of  the  hands  is  the 
prolonged  and  thorough  cleansing  with  flowing  warm  water 
and  soap. 

Kiimmell  has  used  marbledust  soap  for  11  years,  but 
recommends  Schleich's  marble  soap,  which  is  prepared  in  the 
pharmacy  of  the  hospital,  as  the  soap  sold  in  the  market  is  not 
what  it  should  be. 

The  hands  are  washed  in  running  hot  water  for  ten  minutes, 
during  which  time  the  finger  nails  receive  careful  attention,  and 
the  aseptic  brush  is  used  with  vigor.  The  hands  are  then 
rubbed  v»^ith  gauze  sponges  saturated  first  with  alcohol  and 
lastly  with  ether.  Immediately  before  the  operation  is  com- 
menced the  hands  are  once  more  rubbed  with  alcohol  and 
bichlorid  of  mercury  solution. 

Preparation  of  Dressing  Mateinal  and  Instruinents. — The 
sterilization-room,  separated  from  the  operating-room  by  a  glass 
door,  is  supplied  with  all  modern  means  of  sterilization.  Every- 
thing that  is  to  be  brought  in  contact  with  the  wound  is  ren- 
dered aseptic  by  boiling  or  steam  sterilization  before  it  is 
brought  into  the  operating-room.  The  orderly  arranges  needles 
and  instruments  and  places  them  in  pans  filled  with  sterile 
water  on  a  table  within  easy  reach  of  the  operator.  The  instru- 
ments are  wrapped  in  a  linen  cloth  and  are  sterilized  in  a 
Lautenschlager  apparatus,  and  the  wrapper  is  not  removed 
until  they  are  to  be  used. 

Silk  is  sterilized  by  boiling  in  bichlorid  of  mercury  solu- 
tion, 1 : 1,000. 


Catgut  is  boiled  in  a  saturated  solution  of  ammonium  sul- 
fate, according  to  the  method  of  Elsherg. 

Preparation  of  Ammonium  Sulfate  Catgut. — Selection  of 
good  raw  material  is  important.  The  catgut  is  wound  upon  a 
square  glass  plate  with  projecting  margins,  in  order  to  expose 
the  threads  fully  to  the  boiling  solution,  as  they  touch  the  plate 
only  at  four  points.  The  boiling  is  done  in  an  enameled  pot 
and  is  continued  for  half  an  hour,  when  the  plate  is  removed 
with  a  pair  of  sterilized  forceps  and  rinsed  in  sterilized  Water. 

For  a  short  time  the  catgut  is  immersed  in  alcohol  to  harden 
it,  when  it  is  placed  in  sterilized  oil  of  juniper  ready  for  use. 
Catgut  and  silk  are  kept  in  bottles  with  a  wide  neck  securely 
closed  with  a  glass  cork,  which  is  removed  when  the  material 
is  needed  and  a  nickel  cover  sterilized  by  boiling  substituted. 
Through  a  central  perforation  in  this  cover  the  threads  are 
brought  out.  From  the  time  the  sterilization  is  completed  no 
one  touches  the  silk  or  catgut  except  the  operator,  who  threads 
his  own  needles.  The  one  who  sterilizes  the  material  and  the 
operator  are  the  only  two  persons  responsible  for  the  asepticity 
of  the  suturing  material.  The  catgut  prepared  by  this  method 
is  firm,  ties  easily  and  securely,  and  remains  in  the  tissues  for 
three  to  four  weeks  and  more.  Dr.  Sick  had  recently  an  oppor- 
tunity to  examine  a  buried  suture  four  weeks  after  the  opera- 
tion, and  found  the  material  softened  but  retaining  its  hold  on 
the  tissues.  Catgut  is  used  almost  exclusively  for  buried 
sutures,  and  a  large  experience  has  shown  the  superiority  of 
the  ammonium  sulfate  over  catgut  prepared  by  any  other 
method. 

Elsberg's  method  of  catgut  sterilization  is  so  simple  and  so 
sure  in  its  results  that  it  soon  will  find  its  way  into  all  hospitals, 
and  it  cannot  be  recommended  in  too  strong  terms  for  general 
adoption  in  private  practice. 

Incision.— T>T.  Kiimmell  is  in  favor  of  a  small  incision. 
Even  in  operations  for  intestinal  obstruction  he  does  not  make 
the  incision  as  long  as  he  advised  a  number  of  years  ago.  With 
increasing  experience  the  incisions  are  made  smaller.  A 
median  incision  is  made  in  all  operations  upon  the  stomach, 
pancreas  and  in  all  gynecologic  operations.  In  appendix  opera- 
tions all  muscular  layers  are  incised  to  the  requisite  extent. 
If  the  uterine  adnexa  are  involved  the  incision  is  made  in  pref- 
erence along  the  outer  border  of  the  rectus  muscle.  In  opera- 
tions upon  the  gallbladder  a  vertical  incision  is  made,  begin- 
ning at  the  costal  arch.  All  abdominal  incisions  are  made 
quickly.  With  one  stroke  of  the  knife  all  tissues  are  divided 
down  to  the  peritoneum.  The  peritoneum  is  incised  separately 
and  the  incision  enlarged  with  blunt-pointed  scissors.  With 
small  vulsellum  forceps  the  peritoneum  and  skin  are  grasped 


at  bleeding  points,  rendering  the  use  of  hemostatic  forceps 
unnecessary.  This  manner  of  dealing  with  the  abdominal 
incision  is  noteworthy,  and  deserves  imitation  by  all  abdom- 
inal surgeons.  Drainage  of  the  peritoneal  cavity  is  seldom 
resorted  to.  The  abdominal  cavity  is  never  flushed.  Blood  and 
other  fluids  are  removed  and  the  surfaces  dried  with  gauze 
sponges. 

The  incision  is  closed  with  four  rows  of  sutures  ;  the  first 
embraces  the  peritoneum,  the  second  the  muscular  layers,  the 
third  the  fascia  and  the  fourth,  of  silk,  the  skin  and  deep  fascia. 
The  wound  is  covered  with  a  sterile  compress,  held  in  place  by 
strips  of  perforated  adhesive  plaster.  The  silk  sutures  are 
removed  on  the  seventh  or  eighth  day. 

After-treatment. — As  a  rule  the  fate  of  the  abdominal  cavity 
is  decided  after  suturing  of  the  incision.  In  case  of  collapse  an 
intravenous  infusion  of  a  liter  of  saline  solution  is  made  at  once 
and  if  necessary  is  repeated  in  a  few  hours.  This  expedient  is 
resorted  to  in  all  cases  when  the  pulse  exceeds  120.  Pain  is 
subdued  by  the  administration  of  morphia.  Vomiting  should 
be  prevented  by  withholding  all  food  and  fluids  by  the  stomach. 
If  no  vomiting  takes  place  coffee  and  tea  are  given  in  small 
quantities  24  hours  after  the  operation.  Ice  is  never  given. 
The  sense  of  thirst  is  relieved  by  rinsing  the  mouth  with 
acidulated  fluids.  If  vomiting  persists  for  more  than  48  hours 
peritonitis  must  be  suspected.  A  diffuse  pronounced  perito- 
nitis results  in  death  and  all  efibrts  to  prevent  a  fatal  termina- 
tion are  useless.  Laxatives  after  laparotomy  for  the  pre- 
vention of  peritonitis  have  been  abandoned.  The  rectal  tube  and 
injection  are  relied  upon  in  relieving  tympanites  and  in  securing 
action  of  the  intestines.  If  glycerin  injections  prov^  fruitless, 
syrup  and  milk  seldom  fail.  If  rectal  alimentation  becomes 
necessary  three  injections  of  sugar,  salt,  yolk  of  egg,  and 
cognac  are  given  every  24  hours.  Forced  nutrition  advised  by 
Leube  consists  in  the  subcutaneous  injection  of  sterilized  olive 
oil  underneath  the  fascia  of  the  thigh  in  quantities  varying 
from  40  to  60  grams.  If  the  patient  requires  energetic  stimula- 
tion camphor  is  added  to  the  oil.  It  will  be  seen  from  the 
foregoing  that  the  after-treatment  in  many  respects  differs  from 
that  in  general  use  elsewhere.  As  the  changes  made  are  based 
upon  an  enormous  experience  the  advice  given  deserves  the 
serious  consideration  of  all  surgeons. 

Dr.  KmmnelPs  Operations.— I  was  fortunate  enough  to  find 
Dr.  Kiimmell  at  his  post  after  his  return  from  his  summer 
vacation  and  to  witness  a  number  of  operations,  which  I  will 
describe  briefly : 

Case  I. — Carcinoma  of  cardiac  orifice  of  stotnach ;  gastros- 
toTny.    The  patient  was  an  old  man,   emaciated  almost  to  a 


skeleton  and  very  anemic.  Cardiac  obstruction  was  almost 
complete.  After  the  necessary  preparatory  treatment  gastros- 
tomy was  performed  under  the  influence  of  the  chloroform- 
oxygen  mixture.  An  incision  two  fingers  breadth  below  and 
parallel  with  the  left  costal  arch,  which  divided  the  rectus 
muscle  almost  completely,  was  made.  Stomach  was  very 
small  and  atrophic  and  there  was  extensive  malignant  disease. 
A  small  incision  was  made  in  the  stomach  as  near  as  possible 
to  the  cardiac  orfice  and  a  Xelaton  catheter  the  size  of  a  large 
lead  pencil  was  inserted  and  fastened  in  its  position  with 
two  stitches  of  fine  silk.  Two  inches  of  the  catheter  were  then 
sewed  over  according  to  Witzel's  method.  The  anterior  wall 
of  the  stomach  around  the  catheter  was  sutured  to  the  parietal 
peritoneum  in  the  upper  angle  of  the  wound  and  the  incision 
closed  with  three  rows  of  continuous  catgut  sutures  and  one  of 
silk  for  the  skin  and  deep  fascia.  Two  ounces  of  port  wine 
were  at  once  poured  into  the  stomach  through  the  catheter. 

Case  II. — Retroversion  of  the  iiterus ;  shortening  of  the 
round  ligaments  by  the  A  lexander  method.  Dr.  Kiimmell  has  per- 
formed this  operation  150  times,  and  is  very  much  pleased  with 
the  immediate  and  remote  results.  In  a  number  of  cases  the 
patients  became  subsequently  pregnant,  and  experienced  no 
inconvenience  before  and  after  delivery.  He  follows  the  advice 
of  Dr.  Goldspohn  and  opens  the  peritoneal  cavity  on  both  sides 
a  modification  of  the  typical  extraperitoneal  method  of  Alex 
ander,  which  he  believes  presents  many  advantages,  as  it  per 
mits  the  insertion  of  the  index  finger,  with  which  adhesions 
can  be  separated,  the  exact  position  of  the  uterus  ascertained 
and  with  which  reposition  of  the  dislocated  uterus  can  be  made 
Incision  was  made  over  the  entire  length  of  the  inguinal  canal 
Round  ligament  was  found  and  isolated  in  the  upper  part  of  the 
canal.  The  ligament  was  followed  in  a  downward  direction 
and  torn  from  its  insertion.  By  making  traction  on  the  liga- 
ment, the  parietal  peritoneum  was  drawn  forward  in  the  form 
of  a  funnel  and  was  incised  with  scissors  above  the  ligament. 
With  the  index  finger  introduced  through  the  slit  in  the 
peritoneum  the  necessary  exploration  was  made,  and  by  traction 
on  the  ligament  and  pressure  against  the  posterior  surface  of 
the  uterus  complete  reposition  of  the  displaced  organ  effected. 
With  two  catgut  sutures  the  pillars  of  the  canal  and  ligament 
were  transfixed.  The  free  end  of  the  ligament  was  then  used 
as  a  living  suture,  using  for  this  purpose  a  large,  short,  flat, 
curved  needle  with  which  three  stitches  were  made,  including 
the  firm  fascia  of  the  external  oblique.  The  ligament  was 
fastened  to  this  fascia  with  two  catgut  sutures  and  the  project- 
ing part  cut  off  even  with  the  muscular  layer.  Suturing  of  small 
superficial  wound  was  done  with  silk.  The  same  operation  was 
done  on  the  opposite  side. 

Case  III. — Inoperable  carcinoma  of  the  rectum ;  left  iliac 
sigmoidostomy.  Under  general  anesthesia  an  incision  was  made 
through  all  abdominal  layers,  three  inches  in  length  two  fingers' 
breadth  above  and  parallel  with  Poupart's  ligament.  The  dis- 
tended sigmoid  flexure  was  readily  found  and  brought  forward 
into  the  wound.  The  surface  of  the  bowel  was  sutured  first  to 
the  peritoneum,  then  the  muscular  layer,  next  fascia  and  finally 
the  skin  with  continuous  catgut  sutures.  Visceral  incision 
will  be  made  24  hours  later  without  an  anesthetic. 

Case  IV.  —  Genn  valgum;  transverse  linear  osteotomy. 
The  patient  was  a  baker,  aged  19.  Right  limb  was  affected, 
deformity    being    far    advanced       Under    general    anesthesia 


an  incision  was  made  down  to  the  bone  an  inch  in  length  at  a 
point  corresponding  with  the  upper  margin  and  internal 
border  of  the  patella.  With  an  osteotome  S  inch  in  width 
the  bone  was  incised  transversely  until  the  fracture  could  be 
completed  by  manual  force.  The  bone  was  very  dense  and  the 
chisel  had  to  be  reinserted  three  times  before  it  was  possible  to 
fracture  the  remaining  part  of  the  bone.  No  sutures.  The 
wound  was  covered  with  a  small  sterile  dressing.  After  correc- 
tion of  the  malposition  the  limb  was  immobilized  upon  a  well 
padded  posterior  splint.  In  a  few  days  a  plaster-of-paris  dress- 
ing will  be  applied  and  will  remain  until  bony  consolidation  is 
complete. 

Case  V. — Relapsing  appendicitis ;  appenclicectomy .  The 
patient,  a  young  man,  had  six  attacks  within  as  many  months. 
Last  attack  occurred  13  days  ago.  Acute  symptoms  subsided 
a  few  days  ago.  There  was  no  temperature,  no  swelling. 
Oblique  incision  was  made  in  line  of  McBurney's  point,  dividing 
all  of  the  layers  of  the  abdominal  wall.  Appendix  was  imbedded 
in  a  mass  of  adhesions  behind  the  cecum.  There  was  a  small 
abscess  around  the  tip  of  the  appendix  in  communication  with 
perforation.  Meseuteriolum  clamped  in  sections  and  tied  after 
removal  of  appendix.  Appendix  was  ligated  at  the  base  with 
fine  silk.  Mucous  membrane  of  stump  was  excised  with  curved 
scissors  and  raw  surfaces  sutured  together  separately.  Stump 
was  buried  by  sewing  over  it  the  adjoining  serous  surfaces. 
Pus  was  carefully  wiped  from  abscess  cavity,  which  was  packed 
with  a  strip  of  eophen  gauze  which  was  brought  out  at  the 
upper  angle  of  the  wound.  Incision  was  closed  with  etagen 
continuous  catgut  sutures.  Skin  was  sutured  separately  with 
silk.  A  small  absorbent  dressing  was  held  in  place  with  strips 
of  perforated  adhesive  plaster. 

Case  YI.— Intestinal  obstriiction ;  laparotomy.  The  pa- 
tient was  a  woman,  aged  30.  For  several  months  she  had 
repeated  attacks,  which  from  the  symptoms  resembled  in 
many  respects  relapsing  appendicitis.  Tympanites  was  well 
marked,  especially  in  the  upper  segment  of  the  abdomi- 
nal cavity.  No  swelling  could  be  detected  in  the  ileo- 
cecal region.  Temperature  38°  C.  There  was  constipation 
and  occasional  attacks  of  vomiting.  Considering  the  uncer- 
tainty of  the  diagnosis,  the  incision  was  made  along  the 
outer  border  of  the  right  rectus  muscle.  Patient  in  Tren- 
delenburg position.  Appendix  was  small  and  presented  no 
macroscopic  lesions.  Appendectomy.  A  cystic  right  ovary 
was  removed.  Tube  was  removed  separately.  Upper  part  of 
small  intestine  was  distended  and  very  vascular.  Lower 
part  of  ileum  was  pale  and  collapsed.  Eventration  and  careful 
examination  failed  to  demonstrate  the  existence  of  a  mechanic 
obstruction.  Cecum  was  also  distended  and  vascular.  Reduc- 
tion of  intestines  was  facilitated  by  lifting  the  margins  of  the 
abdominal  incision  with  short  vulsellum  forceps,  and  by  cover- 
ing the  intestines  with  an  artificial  peritoneum  of  gauze  over 
which  uniform,  gentle,  manual  pressure  was  made.  Suturing 
of  abdominal  incision  was  done  in  the  customary  manner.  The 
operation  relieved  the  symptoms  of  obstruction,  and  the  patient 
was  progressing  favorably  four  days  later.  (Was  this  a  case  of 
adynamic  obstruction  caused  by  intestinal  sepsis?)  Toward 
the  completion  of  the  operation  the  patient  became  somewhat 
collapsed,  and  an  assistant  resorted  promptly  to  intravenous 
infusion  of  one  liter  of  saline  solution.  The  pulse  and  general 
appearance  improved  visibly  in  a  short  time  after  the  infusion. 


10 


Case  YII. — Renal  tuberculosis;  nephrotomy;  freezing 
point  of  the  blood  as  a  diagnostic  and  prognostic  resource 
in  renal  affections.  This  was  a  case  of  unusual  interest, 
as  it  gave  an  opportunity  for  the  operator  to  give  a  compre- 
hensive account  of  the  diagnostic  and  prognostic  value  of  the 
freezing  point  of  the  blood  in  affections  of  the  kidneys  and  renal 
surgery.  Dr.  Kiimmell  has  made  a  very  thorough  study  of 
this  subject,  and  he  has  found  this  test  reliable  in  all  cases  in 
which  it  was  applied.  The  test  is  a  very  simple  one.  All  that 
is  required  is  a  C.  thermometer,  a  large  test-tube  and  a  freezing 
mixture  of  ice  and  salt  in  a  glass  bottle  with  a  wide  neck.  Two 
ounces  of  blood  are  drawn  from  the  median  basilic  vein  with  a 
cannula  into  the  glass  tube.  Coagulation  must  be  prevented  by 
constant  agitation.  The  glass  tube  is  immersed  in  the  freezing 
mixture — also  the  thermometer.  The  column  of  mercury  falls 
until  the  freezing  point  is  reached,  when  it  rises.  The  observa- 
tions are  made  at  this  time  and  the  result  recorded.  As  a  con- 
trol experiment,  the  freezing  point  of  distilled  water  is  subse- 
quently ascertained  for  comparison.  The  freezing  point  of  nor- 
mal blood  is  0.56°  C.  In  renal  insufficiency  the  freezing  point 
is  lower,  and  falls  with  the  accumulation  of  solid  material  in 
the  blood.  These  facts  were  first  pointed  out  by  Koranyi.  Dr. 
Kiimmell  has  applied  this  test  in  more  than  265  cases,  and  has 
always  found  it  reliable.  He  has  formulated  from  his  experi- 
ences the  following  rules : 

1.  A  freezing  point  of  0.58°  does  not  contraindicate  an  oper- 
ation. 

2.  A  freezing  point  of  0.59°  demands  caution. 

3.  A  freezing  point  of  0.60°  and  below  is  a  positive  contra- 
indication to  any  operative  interference  on  the  kidney. 

In  Case  VII  this  test  showed  a  low  freezing  point  of  the  blood, 
but  still  within  the  range  of  a  justifiable  operative  attempt  short 
of  nephrectomy. 

The  patient  was  a  boy,  aged  14.  He  had  lupus  of  the  face  of 
long  standing.  For  several  months  there  had  been  renal  symp- 
toms. Numerous  bacilli  were  found  in  the  urine.  Right  kidney 
was  much  enlarged.  Chloroform-oxygen  general  anesthesia. 
Right  kidney  was  exposed  by  large  transverse  extraperitoneal 
incision.  The  operator  introduced  his  whole  right  hand 
behind  the  kidney,  liberated  the  upper  pole  and  in  a  few  min- 
utes brought  the  organ  forward  into  the  wound.  Kidney  was 
lobulated,  pale,  soft,  and  at  least  eight  inches  in  length.  From 
the  convex  surface  the  kidney  was  incised  from  pole  to  pole, 
laying  open  freely  the  distended  pelvis  and  calices.  Paren- 
chyma was  pale  and  edematous.  There  was  very  little  hemor- 
rhage. The  immense  visceral  wound,  pelvis,  and  calices  Avere 
tamponed  with  eophen  gauze  and  after  the  kidney  was  replaced 
the  external  wound  was  tamponed  with  the  same  material.  If 
after  this  operation  the  freezing  point  of  the  blood  improves 
nephrectomy  will  be  performed.  A  few  days  after  the  opera- 
tion the  patient  was  doing  well. 

Case  YIll.— Catheterization  of  ureter  in  male.  Dr.  Kum- 
mel  is  an  expert  in  catheterization  of  the  ureter  in  the  male. 
He  says  the  operation  is  much  easier  in  the  male  than  in  the 
female.  He  makes  use  of  the  urethral  cystoscope  manufac- 
tured by  Remiger,  Gebbel  and  Schalle,  Berlin.  The  illumina- 
tion of  the  bladder  with  this  instrument  is  perfect.  So  soon  as 
the  ureteral  orifice  is  in  sight  the  tip  of  the  ureteral  catheter  is 
bent  in  that  direction  by  a  spring,  when  the  catheter  is  advanced 
and  finds  its  way  into  the  ureter  without  any  difficulty.    The 


11 

case  occurred  in  a  man  advanced  in  years  who  came  into  the 
hospital  to  be  treated  for  cystitis.  Ureteral  catheterization  was 
made  as  one  of  the  important  diagnostic  resources.  To  obtain 
the  urine  from  each  kidney  separately  it  is  only  necessary  to 
insert  the  catheter  a  few  lines  beyond  the  ureteral  orifice. 
Catheterization  of  the  left  ureter  was  made  in  a  few  minutes 
with  very  little  discomfort  to  the  patient. 

Case  l^.— Primary  carcinoma  of  liver ;  exploratory  lap- 
arotomy. Progressive  marasmus  and  repeated  attacks  of  vom- 
iting suggested  the  existence  of  malignant  disease  of  the 
pyloric  end  of  the  stomach.  The  patient  was  a  man  between  60 
and  70  years.  Incision  was  made  a  little  to  the  left  of  the 
median  line.  Liver  was  enlarged,  hard,  uneven,  and  under- 
neath the  capsule  numerous  carcinomatous  nodules  could  be 
seen  and  felt.  The  stomach  was  small  and  atrophied.  The 
abdominal  incision  was  sutured  in  the  usual  manner. 

Case  X. — Radical  operation  for  iyiguiyial  hernia  by  a  modified 
Bassini-Kocher  operation.  Dr.  Kiimmell  treats  the  sac  accord- 
ing to  Kocher,  and  modifies  the  Bassini  method  of  obliterating 
the  inguinal  canal  by  placing  the  cord  over  instead  of  underneath 
the  fascia  of  the  external  oblique  muscle.  He  has  performed 
this  operation  in  several  hundred  cases  and  is  well  satisfied 
with  the  results.  Relapse  of  the  hernia  is  almost  unknown, 
and  he  has  never  observed  atrophy  of  the  testicle  as  a  remote 
complication.  General  anesthesia.  Hernia  right  side.  Incis- 
ion was  made  over  entire  length  of  canal.  Sac,  cord  and  ves- 
sels were  isolated  and  lifted  away  from  the  inguinal  canal  with 
a  strip  of  iodoform  gauze.  The  sac  was  opened  and  tip  of  left 
index  finger  inserted  and  employed  as  a  guide  in  separating 
the  sac  from  the  cord  and  its  accompanying  vessels.  Separa- 
tion of  sac  was  done  as  far  as  the  internal  inguinal  ring.  A 
pair  of  closed  hemostatic  forceps  passed  into  the  canal  from 
below,  and  with  it  the  tissues  were  tunneled  from  within 
outward  over  the  neck  of  the  sac.  Through  this  tunnel  forceps 
were  inserted  from  without  inward  and  the  sac  grasped  and 
drawn  tight.  The  neck  of  the  sack  was  securely  stitched  to 
the  firm  fibers  of  the  external  oblique  muscle  and  the  sac 
amputated  close  to  the  sutures.  The  inguinal  canal  was  closed 
with  a  continuous  catgut  suture,  which  included  also  the 
external  oblique  muscle.  The  subcutaneous  fat  and  fascia  were 
sutured  separately  over  the  cord  with  catgut  and  skin  with  fine 
silk.  This  operation  appeared  to  be  perfect  in  every  detail  and 
was  executed  with  the  skill  of  a  master. 

Case  ^il.— Radical  operation  for  inguinal  hernia.  Same 
operation. 

Case  J^ll.— Congenital  dislocation  of  hip-joint;  bloodless 
reduction.  The  patient  was  a  girl  of  4^  years.  Three 
months  ago  it  was  taken  for  granted  that  the  bloodless  reduc- 
tion had  succeeded,  and  the  limb  was  immobilized  in  a  plaster- 
of-paris  dressing.  On  removing  the  dressing  a  few  days  ago 
the  head  of  the  femur  was  found  outside  of  the  acetabulum. 
According  to  the  experience  of  Dr.  Kiimmel  such  failures  are 
by  no  means  of  rare  occurrence.  In  repeating  the  attempt 
reduction  was  effected  and  the  limb  was  at  once  immobilized  in 
a  plaster-of-paris  dressing  at  a  right  angle  to  the  pelvis  and 
forcible  rotation  outward  with  knee  flexed.  The  fixation 
dressing  will  remain  undisturbed  for  three  months. 

Case  XIII. — Myomatous  uterus;  abdominal  hysterectomy. 
The  patient  was  a  multipara,  aged  30.  Trendelenburg  position. 
Subserous  myofibroma  the  size  of  a  billiard  ball  detached  in 


12 


briDgiDgthe  uterus  forward  into  the  wound.  Fundus  of  uterus 
was  enlarged  by  an  intramural  tumor  of  the  same  size.  One  of 
the  ovaries  was  saved.  Broad  ligament  and  uterine  arteries 
were  tied  with  silk.  Vaginal  opening  was  carefully  closed 
with  a  continuous  suture.  Abdominal  incision  was  sutured  in 
the  customary  manner. 

Case  XIV. — Salpingitis ;  salpingostomy  ;  oophorectomy. 
The  patient  was  a  multipara,  aged  32.  A  few  years  ago  a  ventro- 
fixation was  made.  Anterior  uterine  mural  adhesion  drawn 
out  into  a  string  at  least  four  inches  in  length.  The  inflamed 
right  ovary  was  removed.  Right  tube  was  enlarged,  tortuous 
and  fimbriated,  extremity  closed  by  adhesions.  About  an  inch 
of  the  distal  end  of  the  tube  was  excised,  and  as  the  lumen  of 
the  remaining  part  was  open  the  mucosa  was  stitched  to  the 
peritoneal  coat  with  fine  silk  sutures  \\\i\x  the  expectation  of 
restoring  the  functional  utility  of  the  tube. 

Dr.  SicTc's  Surgical  Work.— Dr.  Sick  is  the  second  chief 
surgeon  to  the  hospital.  He  is  a  very  quiet,  modest  man,  who 
finds  his  greatest  satisfaction  in  the  museum,  laboratory, 
morgue  and  operating-room.  I  doubt  if  he  ever  enjoys  a  vaca- 
tion, as  he  is  happiest  w^hen  at  work.  He  is  a  man  of  few  words, 
but  knows  how  to  interest  his  visitors  in  his  operative  work. 
He  is  a  cool,  deliberate  and  dextrous  operator.  He  makes  his 
plans  carefully  and  executes  them  w^ithout  hesitation  and  with- 
out unnecessary  haste.  Every  move  he  makes  is  for  a  definite 
purpose,  and  accomplishes  its  object.  Everyone  w^ho  witnesses 
his  operations  is  impressed  with  the  idea  that  he  is  in  the  pres- 
ence of  a  surgeon  of  unusual  experience.  Dr.  Sick  approaches 
the  most  difficult  task  with  the  same  ease  of  mind  and  body  as 
though  he  were  called  upon  to  perform  the  most  insignificant 
minor  operation.  He  takes  a  justifiable  pride  in  many  of  the 
interesting  specimens  in  his  collection.  He  has  made  a  special 
study  of  acute  osteomyelitis  of  the  sternum,  and  his  anatomic 
and  pathologic  specimens  illustrating  this  subject  throw  a  flood 
of  light  on  this  somewhat  rare  affection.  He  is  now  investi- 
gating the  anatomic  changes  which  take  place  in  the  neck 
of  the  femur  after  amputation  of  the  thigh.  The  angle  of  the 
neck  in  the  course  of  time  is  greatly  diminished,  undoubtedly 
in  consequence  of  traction  made  by  the  weight  of  the  stump. 
A  skull  is  shown  in  which,  years  before  death,  a  piece  of  bone 
nearly  the  size  of  the  palm  of  the  hand  of  an  adult  was  removed 
and  reimplanted.  The  outline  of  this  enormous  disc  is  well 
shown  in  the  specimen,  proving  conclusively  that  the  bone 
temporarily  removed  retained  its  vitality  and  took  an  active 
part  in  the  restoration  of  the  continuity  of  the  skull.  The 
inner  surface  of  the  skull  is  perfectly  smooth,  while  the 
external  table  of  the  implanted  bone  is  slightly  atrophied.  A 
number  of  skulls  show  what  takes  place  after  the  Wagner- 
Wolff  temporary  resection  of  the  skull  for  the  removal  of 
malignant  tumors  of  the  brain.    The  bone  at  the  base  of  the 


18 


flap  always  united  by  bony  union,  while  the  upper  part  was 
always  liftedaway  from  the  marg^in  of  the  cranial  defect  by  the 
gradually  increasing  intracranial  pressure,  leaving  a  gaping 
cleft  for  the  expansion  of  the  intracranial  mass.  A  large  col- 
lection of  ivory  braces  and  screws  for  direct  fixation  of  com- 
pound and  ununited  fractures  show  the  different  stages  of 
absorption. 

A  stomach  is  exhibited  taken  from  a  patient  operated  upon 
for  ulcer  of  the  stomach  ten  years  before  death  from  an  acute 
pulmonary  affection.  A  gastroenterostomy  was  made.  The 
patient  improved  rapidly  after  the  operation  and  digestion 
remained  unimpaired.  The  specimen  tells  an  interesting  story. 
The  communication  between  the  stomach  and  upper  part  of  the 
jejunum  is  large  enough  to  admit  two  fingers.  Near  the 
pylorus  and  extending  along  the  lesser  curvature  of  the  stomach 
is  a  large,  smooth  scar,  corresponding  with  the  location  and 
approximate  size  of  the  hourglass-shaped  ulcer  for  which  the 
operation  was  made.  Dr.  Sick  has  had  an  unusually  large 
experience  in  gynecologic,  abdominal  and  pelvic  operations, 
and  I  was  greatly  pleased  to  witness  his  skill  in  this  depart- 
ment of  surgery.  I  will  describe  very  briefly  two  of  his 
operations : 

Case  I.—Myojibroynas  of  the  uterus;  abdominal  hysterec- 
tomy.  The  patient  was  a  woman,  aged  33,  mother  of  two 
children.  She  had  uterine  hemorrhages  for  more  than  a  year. 
Intrauterine  myoma  the  size  of  a  small  cocoanut  projects  into 
the  vagina  and  was  first  removed.  Laparotomy  in  Trendelen- 
burg position.  Quick  median  incision.  Margins  of  incision 
grasped  with  small  vulsellum  forceps  at  bleeding  points.  A 
splendid  view  of  pelvic  cavity  and  contents  was  obtained.  The 
uterus,  the  size  of  an  adult's  fist,  was  studded  with  subserous 
tumors.  Right  ovary,  tube  and  uterus  were  removed.  Dr. 
Sick  makes  exclusive  use  of  catgut  as  ligature  and  suturing 
material.  Broad  ligament  was  tied  in  sections.  After  tying 
uterine  arteries,  the  uterus  was  excised  rapidly  with  blunt- 
pointed,  curved  scissors.  Vaginal  opening  was  hemmed  with 
continuous  catgut  suture,  which  checked  all  hemorrhage.  The 
opening  was  then  accurately  closed  with  peritoneal  catgut 
sutures.  Abdominal  incision  sutured  with  four  tiers  of  con- 
tinuous catgut  sutures.  Small  absorbent  dressing  held  in  place 
by  strips  of  perforated  adhesive  plaster  finished  the  opera- 
tion. 

Case  11.— Appendicitis  simulatirig  salpingitis ;  appendec- 
tomy. Patient  was  a  married  woman,  aged  30.  Four  years  ago  she 
had  a  severe  attack  of  what  was  considered  at  the  time  pelvic 
peritonitis.  Four  weeks  ago  she  was  delivered  of  a  child.  She 
has  never  been  free  from  pain  in  the  right  iliac  region  since  the 
first  attack.  Probable  diagnosis,  pyosalpinx  on  right  side. 
Bimanual  palpation  under  anesthesia  detected  a  hard  swelling 
in  the  region  of  the  right  fallopian  tube.  Trendelenburg  posi- 
tion. Rapid  median  incision.  A  coil  of  small  intestine  was 
found  adherent  to  the  parietal  peritoneum  in  the  right  iliac 
fossa.    In  separating  the  firm  adhesions  with  finger  and  blunt 


14 


instruments,  a  fecal  stone  the  size  of  a  large  bean  escaped.  In 
the  small  cavity  in  which  the  stone  was  lodged  the  open  termi- 
nal end  of  the  appendix  was  discovered.  Excision  of  walls  of 
abscess-cavity  and  perforated  appendix.  The  raw  surfaces  on 
the  intestine  and  parietal  peritoneum  were  carefully  covered 
with  healthy  peritoneum  by  suturing  with  catgut.  Adhesions 
extended  to  the  fundus  of  the  subinvoluted  uterus.  Abdominal 
incision  was  closed  wath  four  rows  of  continuous  catgut 
sutures.    No  drainage. 

A  visit  to  the  general  hospital  Hamburg- Eppendorf  should 
include  inspection  of  the  bath-house,  gymnasium,  massage- 
room,  orthopedic  department,  and  morgue.  The  bath-house, 
a  model  of  its  kind,  is  in  charge  of  competent  orderlies 
and  trained  nurses.  The  gymnasium  has  a  complete  outfit 
of  Zander  mechanical  apparatus  for  passive  and  active  exer- 
cise of  every  muscle  and  joint  of  the  body.  This  outfit  was 
purchased  at  an  expense  of  30,000  marks.  Instruction  in  mas- 
sage, theoretic  and  practical,  is  given  free  of  expense.  After 
three  months  the  candidates  for  this  kind  of  hospital  and  pri- 
vate work  are  examined  and  if  found  competent  receive  a  cer- 
tificate of  proficiency  from  the  orthopedic  department.  Corsets 
and  apparatus  of  all  kinds  are  made  by  skilled  workmen. 
From  five  to  twelve  necropsies  are  made  daily  in  the  morgue 
by  men  who  are  familiar  with  that  kind  of  work  and  experts  in 
gross  and  microscopic  anatomy.  From  w^hat  I  have  seen  in 
various  places  on  this  trip  I  have  come  to  the  conclusion  that  the 
practitioner  can  see  and  learn  more  in  one  day  in  the  general 
hospital  Hamburg-Eppendorf  than  in  any  other  place  on  the 
Continent  or  anywhere  else. 
Hamburg,  August  15. 


fKeprinted  from  American  Medicine,  Vol.  V,  No.  2,  pages  6«-68, 
January  10,  1903.] 


HOSPITAL  WORK  OF   DR.  CARL  LAUENSTEIN. 


NICHOLAS  SENN,  M.D., 
of  Chicago. 

One  of  the  best  known  names  in  the  medical  and  social 
circles  of  Hamburg  is  that  of  Dr.  Carl  Lauensteiu.  As  a  sur- 
geon his  name  is  familiar  wherever  surgery  is  practised.  His 
contributions  to  surgical  literature  have  been  many  and  of  great 
scientific  and  practical  value.  His  voice  is  heard  at  every 
annual  meeting  of  the  German  Sur- 
gical Society,  and  never  fails  to 
command  earnest  attention.  Nearly 
every  volume  of  the  transactions 
of  this  society  contains  an  account 
of  his  activity  as  a  surgeon  and 
scientist.  He  speaks  French  and 
English  fluently,  and  is  well  versed 
in  everything  pertaining  to  foreign 
medical  literature.  His  personality 
is  a  striking  one.  He  stands  six 
feet  four  in  his  stockings,  erect  as 
the  fir  tree  of  his  native  home,  and 
is  endowed  with  the  physical 
strength  of  a  giant.  A  man  of  ordi- 
nary size  standing  or  walking  aside 
of  him  experiences  a  keen  sense  of 
his  physical  insignificance  under 
the  shadow  of  his  towering  height. 
He  is  a  typical  blonde,  and  his 
large  azure-blue  eyes  reflect  the 
nobility  of  his  soul.  He  has  reached 
the  fifty-second  milestone  of  his 
busy,  useful  life.  The  son  of  a  cler- 
gyman, he  received  the  most  care- 
ful training  from  early  child- 
hood for  the  profession  of  his 
choice.  He  studied  medicine  at 
the  University  of  Gottingen,  and 

was  the  favorite  pupil  of  the  late  Professor  William   Baum. 
Lauenstein  respected  and  loved  his  teacher  of  surgery.    The 


Carl  Lauenstein  and  his 
smaller  brother  as  privates 
during  the  Franco-Prussian 
war. 


genuine  piety,  profound  learning  and  honest  convictions  which 
characterized  the  life  and  work  of  Professor  Baum  made  a  deep 
and  lasting  impression  on  hi%  pupil,  and  undoubtedly  had 
much  to  do  in  molding  his  subsequent  professional  career. 
Lauenstein  loves  to  relate  little  incidents  in  the  life  of  his 
master.  Many  of  these  little  storiettes  reflect  the  surgical 
practice  of  those  days.  On  one  occasion  an  assistant  had  used  a 
probe  in  exploring  a  foul  abscess  ;  the  professor,  who  wished  to 
examine  a  recent  wound,  called  for  the  instrument,  and  wishing 
to  impress  his  assistants  with  the  importance  of  surgical  clean- 
liness, wiped  the  probe  between  his  lips  and  then  with  a  clean 
and  easy  conscience  used  it  upon  his  patient.  Lauenstein's 
early  student  days  were  eventful.  At  the  outbreak  of  the 
Franco-Prussian  war  he  was  a  medical  student  at  Gottingen. 
He,  like  most  of  the  university  students,  promptly  volunteered 
and  entered  the  military  service  as  a  private  of  a  musketeer 
regiment.  During  the  short,  historic  military  career  he  w^rote 
one  and  often  two  letters  every  day  to  his  anxious,  devoted, 
affectionate  parents.  These  letters  were  preserved,  and  in  1895 
he  published  them  in  book  form  and  presented  this  souvenir  of 
the  war  to  his  mother  on  Christmas  day.  How  his  aged  mother 
appreciated  this  gift  only  a  mother  can  describe  who  has  passed 
through  the  same  bitter  experience.  Lauenstein  was  a  faith- 
ful, heroic  soldier.  He  was  in  action  eleven  times,  and  had 
many  narrow  escapes,  but  Providence  deviated  the  bullets 
aimed  at  him.  His  patriotism  and  sense  of  duty  knew  no 
tK)unds.  On  his  return  home  one  of  his  friends  furnished  the 
explanation  why  he  escaped  uninjured.  He  said  that  during 
one  of  the  battles  a  Frenchman  drew  his  bead  on  him  at  close 
range,  the  next  moment  he  dropped  his  musket  lower,  fully  con- 
vinced that  other  comrades  had  selected  the  same  conspicuous 
target,  and  not  wishing  to  waste  ammunition,  fired  at  a  man  of 
ordinary  size.  In  one  of  his  letters  to  his  parents  he  said  that  if 
he  were  permitted  to  return  home  alive  he  would  never  return 
to  France,  where  he  experienced  all  the  privations  meted  out 
to  the  private  soldier  during  a  forced  campaign  under  the  most 
distressing  climatic  conditions.  He  failed  to  keep  this  promise. 
He  recently  made  a  bicycle  tour  through  France  with  his 
oldest  son,  a  law  student,  and  visited  all  of  the  familiar  battle- 
fields where  he  served  his  country  so  well  32  years  before.  Such 
men  should  be  rewarded  with  a  jeweled  cross  of  gold  instead 
of  one  of  iron.  Dr.  Lauenstein's  opportunities  for  making  prac- 
tical use  of  his  surgical  knowledge  and  skill  have  been 
immense.  He  is  surgeon-in-chief  to  two  of  the  Hamburg  hos- 
pitals and  at  the  same  time  enjoys  a  lucrative  private  practice. 
Bethesda  Hospital. — This  is  a  private  hospital  in  charge  of 
-deaconesses.    It  contains  100  beds,  of  which  50  are  occupied  l)y 


3 

surgical  patients.  Lauenstein  is  the  very  soul  of  this  institu- 
tion. It  is  here  where  his  surgical  methods  can  be  studied  to 
greatest  advantage.  A  new  addition  is  nearly  completed  and 
will  afford  the  necessary  additional  room  for  the  increasing 
demands  on  the  hospital.  The  patients  are  divided  into  three 
classes.  The  first  class  patients  pay  eight  marks  a  day,  the  sec- 
ond five.  Many  of  the  third  class  are  received  as  charity  cases. 
The  wealthy  citizens  contribute  liberally  toward  the  improve- 
ments and  running  expenses  of  this  excellent  institution.  The 
operating-room  is  small,  unpretentious,  but  the  plain,  simple 
facilities  for  asepsis  are  utilized  in  such  a  practical  manner  that 
the  visitor  becomes  convinced  that  the  patients  who  are  oper- 
ated upon  have  received  all  the  essential  prophylactic  care  that 
modern  surgery  can  offer  against  infection.  Lauenstein  places- 
more  weight  on  air  infection  than  most  surgeons.  One  of  his^ 
requirements  in  entering  the  operating-room  is  careful  wiping 
of  the  shoes,  a  task  which  is  performed  in  a  most  conscientious 
manner  by  a  male  servant.  Gloves  are  used  in  operations  upon 
septic  cases,  and  then  only  for  the  purpose  of  protecting  the 
hands  against  contamination.  Instead  of  a  mask  the  hair  and 
beard  are  washed  and  are  kept  moist  with  an  antiseptic  solu- 
tion. The  operator  is  assisted  by  the  house  surgeon  and  three 
Sisters.  One  of  the  Sisters  administers  the  anesthetic,  usually 
chloroform,  by  the  drop  method ;  another  has  charge  of  the 
instruments,  and  the  third  one  handles  the  gauze,  sponges  and 
dressing  material. 

Lauenstein' s  Method  of  Hand  Disinfection. — Lauenstein  has 
made  disinfection  of  the  skin  a  special  study  for  several  years. 
Some  three  years  ago  he  reported  upon  the  results  of  his  scien- 
tific investigations  on  this  subject.  He  made  use  of  all  then 
known  methods  of  disinfection  and  then  removed  a  small 
particle  of  skin  from  the  disinfected  surface  and  under  strict 
aseptic  precautions  transferred  it  to  a  nutrient  medium. 
Without  exception  microbes  developed,  which  led  him  to  the 
conclusion  that  absolute  asepsis  cannot  be  obtained  by  any  of 
the  methods  so  far  employed.  These  observations  taught  him 
the  necessity  of  combining  aseptic  with  antiseptic  measures. 
He  irrigates  wounds  with  a  2%  solution  of  lysol.  His  direc- 
tions for  hand  disinfection  are  the  following: 

1.  Softening  and  washing  of  the  hands  without  brush  in 
warm  water  with  soap,  frequently  changed  until  the  water 
remains  clean. 

2.  Cleansing  and  trimming  of  finger  nails. 

3.  Renewed  washing  in  warm  water  without  brush. 

4.  Final  cleansing  in  warm  water  and  soap  with  use  of  sterile 
brush. 

5.  Drying  with  sterile  towel. 


6.  Thorough  immersion  and  scrubbing  of  fingers  and  hands 
Avith  96%  alcohol  with  use  of  sterile  gauze  sponges  with  special 
reference  to  finger  nails  and  subungual  spaces  continued  for  three 
minutes.  The  field  of  operation  is  prepared  the  evening  before 
operation  and  the  surface  covered  with  a  compress  saturated 
with  a  solution  of  salicylic  acid.  Before  the  operation  the  final 
disinfection  is  made. 

Lauenstein's  Method  of  Catgut  Sterilization. — Lauenstein 
has  given  the  different  methods  of  catgut  sterilization  a  fair 
trial  and  after  finding  them  unsatisfactory  has  adopted  the  fol- 
lowing method : 

The  catgut,  free  from  fat  and  sterilized  by  dry  heat,  is 
immersed  for  eight  days  in  50%  creolin-vasogen.  In  this  very 
active  bactericide  the  catgut  softens  and  swells  and  is  sat- 
urated with  the  creolin-vasogen  throughout.  It  is  then  placed 
in  2%  salicyl- alcohol  to  which  10%  of  glycerin  is  added.  In  this 
solution  the  threads  are  often  turned  over  and  in  this  solution 
it  regains  its  firmness  and  tensile  strength.  Before  use  it  is 
immersed  in  .5%  formalin-alcohol.  He  has  used  catgut  pre- 
pared by  this  method  for  six 
years  with  perfect  satisfac- 
tion. The  bacteriologic  ex- 
aminations of  this  catgut 
made  frequently  by  Profes- 
sor Dunbar  have  always 
proved  its  absolute  sterility. 
Silk  used  for  superficial  su- 
tures is  sterilized  by  boiling. 
Dr.  Lauenstein  regards  reli- 
able catgut  as  the  ideal  ma- 
terial for  ligatures  and  bur- 
ied sutures.  He  has  in  his 
service  a  large  gynecologic 
material.  One  day  he  exam- 
ined three  patients  under 
anesthesia  and  dictated  the 
following  diagnoses:  Sub- 
serous    myofibroma,     solid 

tumor  of  ovary,  large  ovarian  cyst.  All  of  these  patients  were 
operated  upon  three  days  later.  On  the  day  of  my  visit  to  this 
hospital  he  performed  the  first  operation  after  his  return  from 
his  summer  vacation. 


Dr.  Carl  Lauenstein. 


Tuberculosis  of  the  Knee-joint :  Amputation  of  Thigh  After 
Resection  of  Joint  had  Failed. — The  patient  was  a  woman, 
aged  56,  who  entered  the  hospital  two  months  ago,  suffering 
from  advanced  tuberculosis  of  the  left  knee-joint.  Typical 
resection  was  made  with  faint  expectation  of  a  successful  result 


owing  to  her  advanced  age  and  the  extent  of  the  disease.  The 
wound  healed  only  in  part  and  the  extensive  recurrence  left  no 
doubt  concerning  the  propriety  of  resorting  to  a  mutilating 
operation.  Patient  was  anemic  and  considerably  emaciated ; 
chloroform  anesthesia ;  elastic  constriction  at  base  of  thigh ; 
long  anterior  and  short  posterior  cutaneous  flaps  ;  remaining 
soft  tissues  were  divided  down  to  the  bone  with  one  sweep  of 
the  knife;  soft  tissues  were  retracted  with  two  folded  gauze 
bandages.  After  reflection  of  periosteum  with  elevator  cross 
section  of  bone  with  a  bow  saw,  the  femoral  artery  and  vein 
were  isolated  separately  and  tied  with  catgut.  Careful  search 
was  made  for  the  intramuscular  branches,  which  were  seized 
with  hemostatic  forceps.  So  thoroughly  was  this  done  that 
when  the  constrictor  was  removed  no  further  use  of  the  forceps 
became  necessary.  The  flaps  were  united  with  silk  sutures 
leaving  both  angles  of  the  wound  open  for  gauze  drainage. 
The  wound  was  thoroughly  flushed  with  a  2%  solution  of  lysol 
before  and  after  suturing.  A  few  layers  of  loose  sterile  gauze, 
next  a  thick  layer  of  aseptic  absorbent  cotton,  a  cushion  of 
wood  wool  and  a  second  layer  of  cotton  held  in  place  with  a 
gauze  roller,  which  also  included  the  pelvis,  constituted  the 
dressing. 

In  the  absence  of  unfavorable  symptoms  the  first  dressing 
is  not  disturbed  for  two  weeks.  With  the  methods  he  now 
employs  Dr.  Lauenstein  looks  with  confidence  to  his  results. 

Harbor  Hospital.— This  is  a  government  hospital  built  and 
supported  by  the  city  of  Hamburg.  Dr.  Lauenstein  is  the 
surgeou-in-chief,  assisted  by  four  salaried  resident  physicians. 
The  hospital  is  intended  for  emergency  cases,  and  its  interior 
construction  corresponds  with  this  purpose.  The  wards  are 
well  furnished,  well  lighted,  and  well  ventilated.  It  contains  a 
motley  population,  as  it  is  likewise  the  refuge  for  the  sick  and 
injured  sailors  of  all  nations  who  frequent  the  great  mercantile 
harbor  of  Hamburg. 

This  is  the  place  in  Hamburg  to  make  a  practical  study  of 
accidental  surgery.  Among  the  injuries  brought  here  almost 
daily  are  fractures,  dislocations,  sprains  and  burns ;  stab  and 
gunshot  wounds  are  comparatively  rare. 

The  dressing  and  operating-rooms  are  constructed  upon  the 
most  improved  plans,  and  are  splendidly  equipped.  With  all 
such  conveniences  it  must  be  a  source  of  gratification  and 
pleasure  to  practise  emergency  surgery.  The  Rontgen  appa- 
ratus and  rooms  are  in  constant  use,  and  in  charge  of  an  expert. 
A  complete  outfit  for  photography  turns  out  daily  the  most 
interesting  illustrations  of  fractures,  dislocations,  and  other 
injuries.  Dr.  Lauenstein  is  now  making  a  special  study  of 
spiral  fractures.  He  has  the  requisite  material  at  his  disposal 
to  elucidate  this  subject  from  a  scientific  as  well  as  a  practical 
standpoint.  Much  has  been  said  and  written  concerning  this 
particular  anatomic  form  of  fractures,  but  more  light  is  needed 
to  comprehend  fully  the  mechanism  of  their  production.    A 


Q 


number  of  beautiful  Rontgen  illustrations  were  shown  of  spiral 
fracture  of  the  tibia  and  fibula.  In  fracture  of  both  bones» 
the  seat  of  the  injury  involv^ed  the  lower  part  of  the  tibia,  while 
the  fibula  yielded  near  the  upper  extremity.  Reduction  and 
retention  by  proper  means  of  fixation  offer  no  particular  diffi- 
culties, and  the  results  are  usually  very  satisfactory.  Dr.  Lau- 
enstein  intends  to  present  the  paper  he  is  preparing  on  the 
nature  and  treatment  of  this  fracture  on  the  occasion  of  the 
eightieth  birthday  of  his  Excellency  Professor  von  Esmarch^ 
which  will  be  celebrated  in  the  birthplace  of  that  distinguished 
surgeon  next  .January.  The  paper  will  be  profusely  illustrated » 
and  will  be  looked  for  with  interest  by  the  profession,  as  it  will 
clear  up  a  number  of  doubtful  points  in  the  etiology  of  spiral 
fractures.  The  nursing  in  this  hospital  in  the  male  wards  is 
done  exclusively  by  trained  male  nurses.  The  scrupulous  clean- 
liness throughout  the  entire  institution  reflects  credit  upon  the 
director  as  well  as  upon  the  efficient  and  well-organized  nurs- 
ing force. 

The  city  morgue  is  located  in  the  hospital  grounds.  Here 
is  a  good  place  to  make  a  practical  study  of  legal  medicine,  as 
a  number  of  postmortems  are  made  daily  by  an  expert,  and  the 
causes  of  death,  accidental  and  otherwise,  are  investigated  with 
a  view  of  satisfying  all  legal  requirements. 

The  detention  department  is  an  interesting  part  of  the  hos- 
pital. This  serves  as  a  temporary  asylum  for  cases  of  acute 
insanity,  delirium  tremens,  etc.  Violent  patients  are  confined 
in  single  rooms  having  an  iron  door,  which  is  locked.  The 
room  contains  nothing  but  a  leather-covered  mattress  for  a  bed» 
About  six  cells  are  always  occupied  by  delirium  tremens 
patients.  Tn  one  cell  we  found  a  man  in  shirt  sleeves  facing 
the  rear  wall  reaching  with  trembling  hands  for  red  currants 
which  he  saw  distinctly  on  the  bare  white  wall  but  always 
eluding  his  greedy  grasp.  Lauenstein  has  abandoned  the  use  of 
alcoholic  stimulants  in  the  treatment  of  delirium  tremens  after 
a  trial  of  over  20  years.  He  has  become  satisfied  and  firmly 
convinced  that  recovery  takes  places  more  speedily  without 
than  with  alcohol.  He  looks  upon  the  disease  as  an  intoxica- 
tion and  reasons  very  properly  that  the  sooner  the  cause  is 
removed  the  more  sure  and  prompt  will  be  the  recovery.  So 
long  as  the  patients  are  violent  they  are  confined  in  a  cell. 
Small  doses  of  morphia  and  chloral  hydrate  are  given  to  pro^ 
cure  sleep.  Much  stress  is  laid  on  the  administration  of  con- 
centrated fluid  nourishment.  If  on  admission  of  the  patient 
there  is  reason  to  believe  that  the  stomach  contains  alcohol  it  is. 
evacuated  by  siphonage.  The  acute  symptoms  usually  subside 
in  three  or  four  days,  when  the  patient  is  transferred  to  an 
adjoining  ward,  where  with  other  conv^alescents  he  receives  the 


appropriate  after-treatment  and  where  he  remains  until  recovery 
is  complete.  It  is  said  that  most  of  these  patients  return  about 
every  six  months  with  the  same  disease  and  pass  through  the 
same  course  of  treatment.  In  Germany,  like  elsewhere, 
delirium  tremens  is  caused  by  the  excessive  use  of  spirits ;  beer 
drinkers  seldom  succumb  to  this  disease. 

The  medical  tourist  visiting  Hamburg  should  not  neglect  to 
make  a  visit  to  the  Harbor  Hospital,  as  he  will  be  sure  to  find 
here  many  things  of  the  utmost  scientific  and  practical  interest 
and  will  always  meet  a  cordial  reception  by  its  genial  medical 
director,  Dr.  Carl  Lauenstein. 

On  board  S.  S.  "  Blucher,"  August  25. 


(Reprinted  from  American  Medicine,  Vol,  V,  No.  3.  pages  105-108 
January  17,  1903.]  ' 


A  COMPARISON  BETWEEN  FOREIGN  AND  AMERI- 
CAN SURGERY. 

BY 

NICHOLAS  SENN,  M.D., 
of  Chicago. 

The  average  physician  seldom  sees  more  than  the  hospitals 
of  his  own  country.  It  is  a  great  privilege  and  a  rich  experi- 
ence to  have  an  opportunity  to  visit  the  hospitals  of  four  conti- 
nents in  succession,  and  to  study  their  facilities,  scope  of  work, 
and  methods  pursued  in  the  treatment  and  care  of  the  sick. 
Such  an  unusual  opportunity  presented  itself  to  me  on  my 
recent  mission  to  St.  Petersburg  and  long  journey  to  the  Orient. 
This  trip  was  not  one  purely  of  pleasure  or  recreation.  It 
included  many  hardships,  as  the  journey  through  Asia  and 
Egypt  was  made  in  midsummer,  when  the  heat  was  greatest  and 
the  pestiferous  insects  most  numerous  and  in  best  fighting  con- 
dition. After  the  adjournment  of  the  Seventh  Conference  of 
the  International  Red  Cross  the  main  object  of  my  tour  was  to 
familiarize  myself  with  the  present  surgical  methods  in  the  dif- 
ferent hospitals  of  the  countries  through  which  I  traveled.  My 
observations  were  made  in  France,  Germany,  Russia,  Turkey, 
Syria,  Palestine,  Egypt,  Austria,  England,  Sweden,  and 
America,  and  have  been  briefly  described  in  the  pages 
of  this  journal.  I  found  everywhere  satisfactory  proof 
that  our  profession  is  a  truly  international  one,  bound 
together  without  regard  to  color,  religion,  or  politics 
by  a  strong  tie  of  a  common  desire  to  advance  science 
and  benefit  humanity.  I  have  become  more  convinced 
than  ever  that  this  bond  of  union  is  stronger  in  the  medi- 
cal than  any  other  of  the  learned  professions.  The  desire 
and  genuine  willingness  to  learn  and  to  instruct  are  more  pro- 
nounced among  medical  men  than  any  other  class.  I  also 
became  satisfied  that  modern  progress  in  medicine  and  surgery 
has  no  geographic  limits.  The  medical  men  throughout  the 
entire  civilized  world  are  all  engaged  in  doing  their  share 
toward  the  advancement  of  science,  and  make  their  contribu- 
tions according  to  surroundings,  opportunities  and  facilities  for 
work.  It  is  not  difficult  to  accomplish  great  results  in  a  well- 
equipped  institution  with  adequate  financial  resources.  I 
admired  particularly  the  scientific  work  in  some  of  the  small 
laboratories  in  the  distant  Orient,  where  many  investigations  of 


far-reaching  value  have  been  made  under  the  greatest  dif- 
ficulties. It  is  work  of  this  kind  that  is  entitled  to  full  recogni- 
tion. The  progress  of  medicine  has  penetrated  the  most  remote 
countries  that  have  any  claim  on  civilization.  The  dawn  of  the 
light  of  original  thought  and  research  is  visible  everywhere, 
and  is  rapidly  forcing  out  of  existence  routine  practice.  The 
science  of  medicine  is  rapidly  retracing  its  steps  from  whence 
it  came.  The  newest  and  best  in  medicine  in  Asia  and  Africa 
comes  from  Europe,  more  especially  from  Germany.  The 
missionary  physicians  have  been  the  pioneers  in  disseminating 
modern  medicine  throughout  the  distant  East,  and  in  establish- 
ing outposts  for  scientific  research.  In  many  of  the  small  labora- 
tories of  the  missionary  hospitals,  original  work  is  being  done 
w^hich  would  be  creditable  to  larger  and  better  equipped  insti- 
tutions. The  spirit  of  awakening  has  taken  a  firm  foothold 
upon  the  soil  of  Asia  and  the  Dark  Continent,  and  will  soon 
bring  about  changes  in  the  care  of  the  sick  and  in  the  preven- 
tion of  disease  that  will  be  a  source  of  gratification  to  those 
who  called  it  into  existence.  The  universities  and  hospitals  of 
Russia  would  compare  favorably  with  those  of  any  other 
country.  The  medical  profession  of  England  enjoys  the  respect 
of  the  government  and  the  public,  and  is  exceptionally  well 
qualified  to  cope  most  successfully  with  the  prevention  and 
treatment  of  disease.  The  lethargy  in  medical  matters  which 
prevailed  in  France  for  a  considerable  length  of  time  has  disap- 
peared and  has  given  place  to  an  energetic  and  enthusiastic 
search  for  the  unknown  in  the  science  of  medicine.  Germany 
and  Austria  have  done  more  for  the  advancement  of  scientific 
medicine  during  the  last  half  century  than  all  of  the  other 
European  countries  combined.  Germany  is  today  the  Mecca  to 
which  medical  students  and  practitioners  make  pilgrimages 
from  all  parts  of  the  world  for  the  purpose  of  obtaining  the 
material  for  a  firm  foundation  upon  which  to  build  the  super- 
structure of  rational  medicine.  Surgery  in  all  of  these  countries 
has  attained  a  high  degree  of  perfection.  Some  of  the  hospitals, 
more  especially  those  supported  by  the  different  governments, 
are  palaces  for  the  sick,  and  are  supplied  with  all  conceivable 
means  and  appliances  for  asepsis. 

It  is  a  great  privilege  to  serve  the  sick  in  such  an  insti- 
tution, as  more  than  one-half  of  the  battle  with  disease  and  acci- 
dents is  fought  by  the  well  trained  nurses  and  the  staff  of 
assistants  with  long  service  and  large  experience.  It  is  in  less 
favored  hospitals  that  the  surgeon  assumes  greater  responsibili- 
ties, and  it  is  the  results  he  records  that  are  withiu  reach  of  the 
general  practitioner  and  which  represent  the  achievements  of 
the  mass  of  the  profession.  All  of  the  European  physicians  are 
well-educated  men,  as  the  entrance  to  their  medical  education 


is  well  guarded,  for  medical  colleges  are  gradualjy  recognizing 
the  importance  of  an  adequate  preliminary  education  as  an 
essential  requirement  for  the  successful  study  and  training  of 
the  medical  student,  but  the  change  from  a  medium  to  the 
highest  standard  is  slower  than  the  present  conditions  demand. 
On  the  other  hand,  I  believe  we  can  claim,  without  fear  of 
contradiction,  that  our  students  apply  themselves  more  closely 
to  their  studies  than  those  of  any  of  the  European  schools,  and 
that  more  of  the  mass  of  our  profession  keep  pace  with  medi- 
cal progress  after  graduation  than  the  physicians  abroad.  The 
keen  competition  and  the  inborn  activeness  and  desire  to 
succeed  that  characterize  the  average  American  physician 
make  him  a  diligent  student  and  a  tireless  practitioner.  There 
is  no  country  in  the  world  where  so  many  medical  journals  are 
read  as  in  America,  and  where  postgraduate  education  is  more 
keenly  appreciated.  Our  active,  well-attended,  numerous 
medical  societies,  local  and  national,  keep  up  the  scientific 
interest  of  the  rank  and  file  of  our  profession,  and  are  the  most 
important  agents  in  stimulating  and  furthering  postgraduate 
education. 

The  vast  clinical  material  of  the  large  European  hospitals  is 
utilized  to  greater  advantage  than  the  clinical  material  here. 
Autopsies  are  more  frequently  made  and  with  greater  thor- 
oughness. All  hospitals  of  any  size  issue  an  annual  report  in 
which  will  be  found  a  concise  retrospect  of  the  medical  and 
surgical  work  for  the  year.  These  publications  are  valuable 
literary  contributions  and  are  eagerly  looked  for  and  liberally 
quoted  by  authors.  Politics  and  church  influence  do  not  cripple 
hospital  management  as  much  in  Europe  as  in  America.  The 
university  professors  are  sure  of  their  hospital  appointment 
until  their  retiring  age  reminds  them  of  the  limitation  of  their 
career  as  teachers.  The  esteem  and  respect  for  medical  men 
abroad  is  much  keener  than  here  and  they  occupy  a  higher 
position  in  the  social  world  and  political  circles.  From  a  prac- 
tical standpoint  the  American  doctor  compares  well  with  his 
colleagues  abroad.  His  natural  aptitude,  his  education  and  train- 
ing harmonize  in  making  him  self-reliant  and  in  making  the 
best  use  of  his  knowledge  at  the  bedside.  The  American  doc- 
tor is  impartial  in  the  selection  of  his  reading  material.  He  has 
no  national  prejudices.  He  absorbs  knowledge  from  all  avail- 
able sources.  All  new  innovations  and  discoveries  are  given  a 
prompt  and  fair  trial.  Many  of  our  physicians  and  surgeons 
make  frequent  visits  abroad  and  return  with  new  ideas  which 
enlarge  their  knowledge  of  disease  and  open  new  fields  for 
their  practice  and  surgical  activity.  It  is  safe  to  make  the 
statemeilt  that  the  gigantic  progress  in  American  medicine  and 
surgery  which  has  been  made  during  the  last  quarter  of  a  cen- 


tury  is  due  largrely  to  what  our  students  and  practitioners  have 
borrowed  in  Europe  and  the  seed  thus  introduced  has  found 
here  a  fertile  soil  and  has  yielded  fruit  a  hundredfold.  From  a 
medical  and  surgical  standpoint  no  country  is  independent,  and 
we  have  reached  a  stage  in  the  growth  of  medical  science  which 
brings  us  up  nearly  to  the  same  level  with  any  of  the  foreign 
countries.  We  have  every  reason  to  look  with  a  justifiable 
pride  on  the  part  America  has  taken  in  the  rapid  development 
of  modern  surgery.  The  teachings  of  Lister  were  eagerly 
grasped  and  promptly  applied  in  practice.  Some  of  the  coun- 
tries on  the  continent  were  slow  in  adopting  the  new  views, 
America  never  hesitated.  From  what  I  have  seen  on  three 
continents  I  can  say  without  hesitation  that  the  aseptic  pre- 
-cautions  which  are  in  use  by  our  surgeons  are  applied  as  thor- 
oughly here  as  anywhere  else.  The  average  American  surgeon 
is  resourceful.  He  may  not  have  the  same  broad  preliminary 
and  professional  education  as  his  European  colleagues,  but  he 
ds  quick  and  determined  in  the  selection  and  use  of  appropriate 
therapeutic  resources.  The  American  surgeon  is  eminently 
practical.  He  is  peculiarly  well  fitted  for  emergency  work. 
He  performs  the  most  difficult  task  with  the  simplest  means 
:and  appliances.  American  ingenuity,  recognized  the  world 
over,  is  well  represented  in  the  medical  profession.  A  visit  to 
'Europe,  Asia,  and  Africa,  with  a  view  of  ascertaining  the 
present  status  of  surgery  in  difl*erent  countries,  awakens  a  new 
interest  in  the  science  and  art  of  medicine  as  they  exist  in  our 
own  country.  On  my  return  from  Europe  I  remained  two  days 
An  Xew  York  for  the  purpose  of  visiting  a  few  of  the  most 
^prominent  hospitals  to  obtain  the  necessary  material  upon 
which  I  could  base  a  practical  comparison  between  foreign  and 
American  surgery. 

Midsummer  is  not  a  good  time  to  see  surgical  New  York, 
as  most  of  the  prominent  surgeons  are  enjoying  their  much- 
.needed  rest  and  recreation  at  that  time.  I  was  fortunate  to 
■find  a  few  of  the  men  I  was  anxious  to  see  at  home  and  at 
work. 

Xew  York  has  four  medical  schools,  all  of  them  in  excellent 
repute.  Among  these  the  College  of  Physicians  and  Surgeons 
is  the  one  that  is  entitled  to  first  place,  by  virtue  of  age  and  the 
elaborate  facilities  it  can  extend  to  its  students  in  its  theoretic 
^nd  practical  courses.  Most  of  the  clinical  teaching  of  this 
college  is  conducted  in  the 

ROOSEVELT   HOSPITAL. 

The  Roosevelt  is  one  of  the  best,  if  not  the  best,  private 
hospitals  in  New  York.  The  name  of  this  institution  com- 
memorates the  philanthropy  of  a  grand-uncle  of  our  present 


i 


Chief  Executive,  who  donated  |1,400,000  for  the  erection  and 
maintenance  of  the  hospital.  The  pride  of  this  hospital  is  the 
W.  J.  Syms  operating-room,  built  at  an  expense  of  $250,000,  the 
gift  of  the  man  whose  name  it  bears,  and  which  was  opened 
for  clinical  teaching  in  1892.  It  is  the  most  costly  and  prob- 
ably the  most  perfect  operating  theater  in  the  world.  The  con- 
struction of  the  interior  of  the  room,  as  well  as  everything 
within  it,  are  such  as  to  adapt  them  for  perfect  aseptic  work. 
The  teacher  of  clinical  surgery  who  visits  this  part  of  the  hos- 
pital, and  who  has  been  less  fortunate  in  his  svirroundings,  is 
perfectly  amazed  at  the  conveniences  which  are  at  the  disposal 
of  his  more  favored  colleagues  here.  In  the  amphitheater  th& 
large  college  clinics  are  held.  Professors  Weir  and  Bull  give 
each  one  clinic  a  week.  Drs.  Brewer  and  Blake  give  each 
three  clinics  to  small  classes  of  20  every  week.  The  students 
of  this  college  have  every  opportunity  to  acquire  the  necessary- 
surgical  skill  that  a  large  material  and  effective  teaching  caiii 
offer.  In  a  small  side  room,  equally  well  equipped,  the  more 
serious  operations,  and  operations  upon  private  patients,  are 
performed.  Another  room  is  devoted  to  septic  cases,  and  in  it 
will  be  found  every  possible  convenience  for  antisepsis.  The 
McLean  operating-room  is  another  very  luxurious  part  of  the 
hospital,  and  is  used  exclusively  for  gynecologic  operations. 
The  students  attend  this  clinic  in  small  sections.  Two  anes- 
thesia rooms  are  within  easy  reach  of  the  main  operating-room. 
The  hospital  has  250  beds.  Two  rooms,  with  two  beds  each, 
near  the  main  operating  theater,  are  reserved  for  patients  wha 
have  undergone  a  serious  operation,  and  there  they  remain 
until  they  recover  from  its  immediate  effects,  when  they  are 
assigned  to  the  wards  where  they  belong.  The  disinfection- 
room  and  two  rooms  for  the  preparation  of  the  dressing  mate- 
rial are  all  that  money  and  skill  could  make  them.  The  hos- 
pital is  well  supplied  with  trained  female  nurses.  The  training- 
school  connected  with  it  has  60  pupils.  The  nurses  are  not  over- 
worked, as  is  the  case  in  many  other  hospitals.  The  wards, 
with  36  beds,  are  attended  to  by  five  nurses.  The  course  of 
study  and  training  for  the  nurses  is  three  years.  During  this 
time  they  are  given  an  opportunity  to  perfect  themselves  in, 
the  nursing  of  a  great  variety  of  patients.  Eight  internes  are 
employed  for  the  surgical  side  alone,  perhaps  more  internes  to 
the  number  of  patients  than  in  most  hospitals.  The  outdoor 
department  is  very  large,  and  two  automobile  ambulances  are 
seldom  at  rest.     Ether  is  the  anesthetic  in  general  use. 

Weir''s  Method  of  Hand  Dismfect ion.— This  method  is  virtu- 
ally the  one  relied  upon  by  all  of  the  surgeons  connected  with 
the  Roosevelt  Hospital,  and  might  well  be  termed  the  Roose- 
velt method.    It  is  as  follows  : 


Thorough  scrubbing  of  hands  with  flowing,  warm,  sterile 
water  and  potash  soap.  About  a  tablespoouful  of  small  crystals 
of  sodium  carbonate  are  then  placed  in  the  palm  of  one  hand,  to 
which  is  added  about  one-third  as  much  of  chlorid  of  lime.  The 
hands  are  thoroughly  rubbed  with  this  mixture  for  some  length 
of  time,  when  they  are  rubbed  dry  with  a  sterile  towel  and  are 
then  rinsed  in  sterile  water.  Professor  Weir  places  much  stress 
on  the  penetrating  power  of  chlorin  gas,  which  reaches 
microbes  in  the  appendages  of  the  skin  and  in  the  layers  of  the 
epidermis  inaccessible  to  many  of  the  antiseptic  solutions. 

The  finger-nails  ref^eive  proper  attention  in  the  mechanical 
treatment  of  the  hands.  After  the  chlorid  disinfection  sub- 
limate solution  is  used  in  the  usual  way  as  an  additional  safe- 
guard. Alcohol  is  occasionally  used,  but  is  not  considered 
essential  in  completing  the  hand  disinfection. 

Professor-, Weir  has  proved  the  reliability  of  this  method  of 
hand  disinfection  by  numerous  bacteriologic  examinations, 
which  invariably  demonstrated  the  absolute  sterility  of  the  sur- 
face thus  treated.  Weir  only  makes  use  of  rubber  gloves  in 
aseptic  cases  \vhen  he  has  to  operate  upon  joints  and  the  abdo- 
men. Dr.  Brewer  uses  gloves  in  all  of  his  operations.  Catgut, 
silk,  silkwormgut,  and  horsehair  are  used  for  suture  material. 
For  buried  sutures  catgut  is  usually  employed. 

Roosevelt  Method  of  Catgut  Sterilization.— Immerse  in  juni- 
per oil  for  4  days;  immerse  in  sulfuric  ether  for  14  days; 
immerse  in  benzine  for  14  days.  Boil  in  alcohol  for  half  an  hour 
to  an  hour,  according  to  the  size  of  the  catgut.  Keep  in  alcohol 
ready  for  use. 

The  iron-stained  silkwormgut  is  a  favorite  material  for 
superficial  sutures. 

The  anesthetic  is  administered  in  the  anesthesia-room  by 
one  of  the  internes.  Two  internes  and  two  trained  nurses  assist 
the  operator.  The  patient  is  prepared  the  evening  before  the 
operation  and  the  final  disinfection  is  made  after  the  patient  is 
fully  under  the  influence  of  the  anesthetic. 

Professor  Weir  has  had  a  long  and  varied  surgical  exper- 
ience. He  entered  the  regular  army  in  1861,  soon  after  his 
graduation,  and  did  most  creditable  service  during  the  Civil 
war.  He  is  well  remembered  by  his  army  colleagues.  During 
his  recent  all-around-the-world  trip  he  visited  the  Philippine 
Islands.  Here  he  found  many  of  his  old  army  friends,  who  did 
all  in  their  power  to  make  that  part  of  his  journey  pleasant  and 
profitable.  Weir's  name  is  intimately  associated  with  the 
surgical  literature  of  America.  He  has  been  an  earnest  student, 
a  successful  surgeon,  an  impressive  teacher,  and  a  prolific 
writer.  He  finds  it  difficult  to  cut  loose  from  his  professional 
work,  as  this  brings  to  him  more  satisfaction  than  idle  recrea- 
tion. During  my  stay  in  New  York  he  came  to  the  city  for  a 
few  days  from  his  vacation  to  perform  a  number  of  operations 
on  private  patients. 


The  patient  operated  upou  the  day  of  uiy  visit  to  the  hospital 
was  a  very  interesting  one. 

The  man  was  about  50,  and  the  subject  of  a  somewhat 
obscure  affection  involving  the  floor  of  the  mouth  and  the 
submental  and  submaxillary  regions.  A  number  of  weeks 
ago  while  taking  outdoor  exercise  in  the  country  he  sud- 
denly experienced  a  sensation  near  the  base  and  lower  surface 
of  the  tongue  as  though  some  sharp  foreign  substance  had 
entered  the  tissues.  A  violent  inflammation  followed,  which 
involved  the  submental  and  submaxillary  regions.  This  in- 
flammation terminated  in  the  formation  of  an  acute  abscess. 
The  swelling  subsided  only  in  part  after  the  abscess  was  incised 
and  a  fistulous  opening  remained.  A  hard  mass  remained  and 
resisted  all  treatment.  A  positive  differential  diagnosis 
between  an  inflammatory  affection  and  malignant  disease  could 
not  be  made.  Under  ether  anesthesia  a  horseshoe-shaped  incis- 
ion was  made  along  the  lower  border  of  the  inferior  maxilla. 
The  flap  was  reflected  as  far  as  the  hyoid  bone.  At  this  stage  of 
the  operation  a  piece  of  the  indurated  tissue  was  excised  and 
the  pathologist  of  the  hospital,  who  was  present,  made  a  frozen 
section  and  examined  it  under  the  microscope.  This  examina- 
tion demonstrated  the  inflammatory  nature  of  the  affection.  By 
a  careful  and  somewhat  difficult  dissection  all  of  the  infected 
glands  and  indurated  tissues  were  thoroughly  excised.  A  large 
rent  in  the  mucous  membrane  of  the  floor  of  the  mouth  was 
made.  A  Penrose  drain  was  inserted  into  one  angle  of  the 
wound  and  the  external  incision  closed  with  fine  iron-dyed 
silkwormgut  sutures.  The  oval  wound  was  tamponed  with  a 
strip  of  iodoform  gauze  saturated  with  compound  tincture  of 
benzoin.  An  external  absorbent  dressing  finished  the  opera- 
tion. 

The  Penrose  drain  is  a  most  excellent  one  for  capillary 
drainage.  It  consists  of  a  tube  of  very  fine  soft  rubber  loosely 
filled  with  absorbent  gauze. 

Weir  has  made  a  very  fine  collection  of  appendicitis  speci- 
mens. The  specimens  are  fastened  on  one  side  of  a  narrow 
strip  of  white  cardboard,  and  on  the  other  side  is  a  drawing 
and  the  legend.  The  specimens  are  preserved  in  cylindric 
glasses  containing  a  formalin  solution.  It  is  hoped  that  this 
valuable  collection  of  pathologic  specimens  will  be  utilized 
for  the  benefit  of  the  general  profession  in  illustrating  the 
pathologic  condition  of  thi^  as  yet  somewhat  obscure  disease. 

Dr.  Brewer  is  one  of  the  attending  surgeons  to  Roosevelt 
Hospital,  and  also  clinical  instructor  in  the  College  of  Physi- 
cians and  Surgeons.  He  is  a  young  surgeon  full  of  promise,  in 
fact,  as  Professor  Weir  informed  me,  "  one  of  the  coming  men." 
During  Weir's  absence  he  does  most  of  the  operative  work.  It 
was  a  source  of  pleasure  and  profit  to  me  to  witness  a  few  of  his 
operations. 

Case  I. — Left  inguinal  hernia,  radical,  by  Bassini\s 
tnethod.  Left  inguinal  hernia  of  many  years'  standing,  for 
which  truss  was  worn  for  a  long  time.  Patient  was  a  man  of 
30,    otherwise    in    excellent    health.      Ether    anesthesia    was 


employed.  Final  disinfection  was  done  before  operation. 
Hand  disinfection  by  Weir's  method.  Incision  was  made  over 
entire  length  of  inguinal  canal.  Partial  isolation  of  sac,  when 
it  was  grasped  with  two  dissecting  forceps,  between  which  it 
was  opened  with  scissors.  Omental  part  of  hernial  contents 
adherent  to  the  sac.  The  omentum  was  separated,  tied  with 
catgut,  and  amputated  at  a  safe  distance  below  the  ligature. 
After  complete  isolation  of  the  sac  it  was  transfixed  at  the  neck 
with  needle  covered  with  catgut  and  tied  and  cut  off  below  the 
ligatures.  The  cord  and  accompanying  vessels  were  now  iso- 
lated and  lifted  out  of  the  canal  with  a  folded  strip  of  iodoform 
gauze.  The  inguinal  canal  was  closed  with  chromicized  catgut 
sutures,  the  material  always  employed  in  performing  this  part 
of  Bassini's  typical  operation.  Next  the  fascia  of  the  external 
oblique  muscle  was  sutured  over  the  cord  with  a  continuous 
suture  of  ordinary  catgut  sterilized  by  the  Roosevelt  method. 
Iron-dyed  silkwormgut  interrupted  suture  was  employed  for 
the  skin.  The  dressing  Avas  sterile  loose  gauze  and  absorbent 
sterile  cotton  held  in  place  by  strips  of  adhesive  plaster  and  an 
abdominal  bandage  with  two  perineal  straps.  It  is  routine 
practice  here  to  drain  such  wounds  with  a  folded  piece  of  sterile 
guttapercha  tissue.  The  wound  is  frequently  douched  with 
warui  physiologic  solution  of  sodium  chlorid. 

Case  II. — FiMula  folloiving  operation  for  acute  appendicitis  ; 
laparotomy;  suturing  of  cecal  perforation.  The  patient,  a 
young  man,  was  operated  upon  by  Dr.  Brewer  two  months  ago 
for  acute  appendicitis.  The  wound  healed  by  primary  inten- 
tion, but  a  small  fistula  remained  which  failed  to  heal.  There 
was  a  very  scanty  seropurulent  discharge  at  times.  It  was  sup- 
posed that  this  fistula  was  caused  and  was  maintained  by  an 
infected  silk  ligature.  The  fistulous  opening  was  enlarged  by 
incising  the  scar  tissue  in  both  directions.  The  fistula  led  into 
the  abdominal  cavity  and  the  incision  had  to  be  enlarged.  The 
great  omentum  and  cecum  came  into  view  and  in  following  the 
fistulous  tract  a  minute  perforation  in  the  cecum  was  found 
where  the  appendix  was  ligated  at  the  first  operation.  The 
perforation  was  thoroughly  disinfected  with  hydrogen  dioxid 
and  was  closed  with  a  continuous  Lembert  suture  of  very  fine 
catgut.  The  external  incision  was  sutured  with  two  tiers  of 
buried  catgut  sutures  and  superficial  iron-dyed  silkwormgut 
sutures.  A  guttapercha  strip  drain  was  placed  in  the  lower 
angle  of  the  wound.  Dry  hygroscopic  sterile  dressing  was 
applied. 

NEW   YORK    HOSPITAL. 

This  is  probably  the  most  elaborate  and  best  equipped 
private  hospital  in  New  York.  It  is  well  endowed  and  it  is 
said  that  it  takes  more  money  to  take  care  of  a  patient  in  this 
than  in  any  other  hospital.  The  number  of  patients  corresponds 
with  that  of  the  Roosevelt.  A  new  wing  wath  50  beds  is  for 
private  patients  and  has  a  separate  staff  of  internes  and  nursing 
force.  The  rooms  are  luxuriously  furnished.  Some  of  them 
have  a  bath-room  and  closet  conveniences.  The  ward  patients 
pay  $2  a  day,  while  the  private  rooms  command  from  $30 
to  $75  per  week.  A  small  but  beautiful  separate  operating- 
room  is  connected  with  this  department  of  the  hospital.  It  is 
in  this  room  that  Dr.   Charles  McBurney  performs   most  of 


his  operations.  The  training-school  of  this  liospital  is  attended 
by  80  pupils,  who  are  required  to  take  a  course  of  three  years 
before  they  are  permitted  to  apply  for  final  examination. 
The  lectures  are  given  by  members  of  the  attending  staff. 
The  general  operating-room  seats  75  students.  No  fee  is 
charged  for  clinical  instruction.  Students  from  all  of  the  four 
medical  schools  take  advantage  of  the  excellent  clinical  teach- 
ing given  here  by  the  large  staff  of  attending  physicians  and 
surgeons.  The  students  of  the  Cornell  Medical  School  take 
private  courses,  for  which  they  pay  a  small  fee.  The  surgical 
staff  includes  the  wellknown  names  of  L.  A.  Stimson,  Francis 
W.  Murray,  A.  B.  Johnson,  Frank  Hartley,  and  P.  R.  Bolton. 
These  men  keep  up  the  high  standard  of  clinical  surgery  of  this, 
one  of  the  best  known  of  the  New  York  hospitals.  Ether  is 
the  anesthetic  of  choice.  The  catgut  is  sterilized  by  Saul's 
method.  Sulfate  of  ammonium  catgut  after  a  fair  trial  has  been 
abandoned,  as  it  was  found  too  brittle  in  tying  the  ligatures  and 
sutures.  Silk  and  iron-dyed  silkwormgut  are  used  for  super- 
ficial sutures.  Hand  disinfection  with  chlorid  of  lime  is  in 
general  use. 

Rubber  gloves  and  caps  are  worn  constantly  by  operators 
and  assistants.  Two  internes  and  two  trained  female  nurses 
assist  the  operator.  A  third  interne  administers  the  anesthetic. 
I  was  fortunate  enough  to  find  Dr.  Alexander  B.  Johnson  at 
work.  He  is  professor  of  surgery  in  the  Cornell  Medical 
College,  and  one  of  the  most  careful  and  skilful  operators  in 
New  York.  On  the  day  of  my  visit  he  had  to  deal  with  two 
very  rare  cases. 

Case  I.—  Ulcer  of  stomach  ;  laparotomy.  The  patient  was  a 
young  man,  who  was  admitted  into  the  hospital  for  hemor- 
rhage from  the  stomach.  The  general  condition  of  the  patient 
was  fair.  No  special  distress  after  eating  and  no  vomiting, 
excepting  during  the  bleeding  attacks.  On  two  occasions  he 
vomited  a  large  quantity  of  blood,  and  decomposed  blood 
passed  per  rectum.  A  median  incision  was  made.  The  stomach 
was  unusual  in  size  and  appearance.  The  pylorus  was  incised 
transversely.  Near  the  pylorus  and  the  small  curvature  of  the 
stomach  two  bleeding  points  were  found  in  the  course  of  a  vein 
of  considerable  size.  Visceral  incision  was  enlarged  and 
mucous  membrane  of  the  stomach  freely  everted  for  inspec- 
tion. The  remaining  part  of  the  interior  surface  of  the  stomach 
was  inspected  through  a  bivalve  rectal  speculum  and  with  the 
aid  of  reflected  light,  but  no  additional  lesions  could  be  dis- 
covered. Hemorrhage  from  the  two  bleeding  points  was 
arrested  with  two  purse-string  sutures  of  catgut. 

Visceral  incision  closed  with  continuous  catgut  suture  for 
mucosa  and  mattress  catgut  Lembert  sutures.  In  closing  the 
external  incision,  catgut  was  used  for  the  peritoneum,  muscu- 
lar layer,  fascia,  and  iron-dyed  silkwormgut  and  fine  silk  for 
the  skin.  Guttapercha  strip  drainage  was  employed,  the  drain 
to  be  removed  in  48  hours.    A  small,   dry  dressing  for    the 


10 

external  woiiud,  held  iu  place  with  strips  of  adhesive  plaster, 
and  abdominal  bandage.  Although  no  distinct  ulceration 
could  be  discovered,  there  must  have  been  minute  erosions  that 
caused  the  venous  hemorrhage,  and  the  treatment  resorted  to 
undoubtedly  succeeded  iu  preventing  recurring  attacks. 

Case  II. — Late  fever  complicating  appendicitis ;  operationy 
exploratory  laparotomy .  A  young  man  was  operated  upon  by 
Dr.  Johnson  four  weeks  ago  for  gangrenous  appendicitis. 
Early  operation.  Appendix  was  removed,  and  the  wound 
healed  by  primary  intention.  Xo  untoward  symptoms  until  a 
few  days  ago  a  high  temperature  developed  which  ranged 
between  104°  to  105°  F.  Other  general  symptoms  confirmed  the 
suspicion  of  the  existence  of  a  retrocolic,  hfpatic,  or  subphrenic 
abscess.  Liver  was  enlarged.  Xo  palpable  swelling  in  the 
ileocecal  region.  Ether  anesthesia  was  employed.  Incision 
was  made  four  inches  in  length  below  and  parallel  with  the 
right  costal  arch.  Liver  was  found  enlarged,  but  no  indica- 
tions of  the  existence  of  an  abscess  within,  above,  or  beneath  it. 
The  incision  was  enlarged  sufficiently  for  the  insertion  of  the 
hand  which  was  employed  in  making  the  necessary  intra- 
abdominal palpation  for  the  detection  of  a  suppurating  focus, 
but  nothing  was  found  that  could  explain  the  remote  post- 
operative fever.  The  abdominal  incision  was  closed  with 
buried  and  superficial  sutures  in  the  usual  manner.  The 
operator  came  to  the  conclusion  that  in  all  probability  the 
remote  septic  complication  was  the  result  of  a  thrombo  phle- 
bitis, which  had  its  origin  at  or  near  the  primary  seat  of  infec- 
tion. 

BELLEVUE   HOSPITAL. 

This  is  the  wellknown,  large,  general  charity  hospital  of 
Xew  York.  It  is  an  old  institution,  but  improvements  have 
been  made  from  time  to  time  so  that  it  serves  its  present  pur- 
pose well.  Its  present  capacity  is  1,000  beds.  The  emergency 
department  is  the  largest  of  any  hospital  in  Xew  York.  Four 
ambulanees  are  in  use  all  the  time,  and  18  horses  are  always  in 
readiness  for  this  service.  The  automobile  ambulances  have 
been  abandoned,  as  not  infrequently  something  would  go 
wrong  when  speed  was  most  required.  The  attending  staff  is 
made  up  largely  of  members  of  the  faculties  of  the  four  medical 
colleges.  It  is  the  great  center  of  clinical  teaching  for  students 
and  practitioners.  Surgical  clinics  are  given  daily  in  the  two 
large  operating-rooms.  The  training-school  for  female  nurses 
is  attended  by  80  pupils,  and  the  school  for  male  nurses  by  90. 
The  course  of  training  is  three  years.  Forty-five  internes  assist 
the  attending  staff  in  taking  care  of  the  vast  clinical  material. 
It  is  estimated  that  24,000  patients  enter  this  hospital  every  year. 
The  morgue  is  one  of  the  finest  in  the  country.  The  mortality 
in  this  hospital  is  for  obvious  reasons  very  high,  as  many  acci- 
dent cases  are  brought  to  its  doors  with  patients  in  a  dying  con- 
dition. The  number  of  postmortem  examinations  made 
annually  sums  up  into  many  thousands.  The  morgue  is  a 
great  school  for  the  study  of  gross  pathology.  The  surgical 
practice    in    this  hospital  is   not    uniform,    as    many    of   the 


11 

operators  pursue  methods  of  their  own.  Dr.  Gill  Wylie  is  one 
of  the  attending  gynecologists.  His  aseptic  precautions  are 
very  simple,  and  yet  efacient.  He  scrubs  his  hands  with  warm 
water  and  ethereal  solution  of  soap,  cleanses  the  finger-nails 
thoroughly,  and  then  resorts  to  chemical  disinfection  by 
immersion  for  a  few  minutes  in  a  solution  of  bichlorid  1  : 8,000 
to  which  three  parts  of  tartaric  acid  are  added.  He  performs  his 
operations  in  a  small  room  connected  with  his  ward.  On  the 
day  of  my  visit  he  was  absent  from  the  city,  and  his  patients 
were  in  charge  of  his  assistant.  Dr.  Lee.  An  Alexander  opera- 
tion was  performed  for  retroversion  of  the  uterus  with  skill 
that  would  have  done  credit  to  his  clinical  teacher.  The 
delirium  tremens  ward  and  detention  wing  are  well  w^orth  a 
prolonged  visit,  as  they  contain  an  abundance  of  the  most 
valuable  clinical  material,  interesting  and  profitable  alike  to  the 
alienist  and  general  practitioner. 

This  completes  a  description  of  my  surgical  observations 
during  the  last  four  months,  and  I  return  to  my  private 
practice  and  college  work  fully  satisfied  that  from  a  surgical 
standpoint  America  compares  well  with  any  of  the  foreign 
countries  I  had  an  opportunity  to  visit.  In  conclusion,  I  desire 
to  thank  all  of  my  colleagues,  near  and  far,  for  the  many 
courtesies  extended  to  me  on  my  long  and  highly-interesting 
and  profitable  journey. 

New  York,  August  29. 


1  Reprinted  from  American  Medicine,  Vol.  V,  No.  13,  pages  503-506, 
March  28,  1903.  i 


GLIMPSES   OF   THE  PRACTICE   OF  MEDICINE  AND 
DISEASES  IN  THE  WEST  INDIES. 

BY 

NICHOLAS   SENN,  M.D., 
of  Chicago. 

Recent  political  events  of  far  reaching  significance  have 
awakened  our  interest  in  and  brought  us  in  closer  touch  with 
the  beautiful  tropical  West  Indies.  Before  the  war  with  Spain 
our  nation  knew  little  of  the  mountain  peaks  of  the  lost 
Atalanta,  but  since  the  fortunes  of  war  have  placed  us  in 
possession  of  one  of  these,  and  destiny  gave  us  an  opportunity 
to  liberate  another  one  from  foreign  rule,  our  eyes  are  turned 
in  the  direction  of  these  landmarks  which  divide  the  great 
Atlantic  Ocean  from  the  blue  waters  of  the  Caribbean  Sea.  The 
West  Indies  offer  so  many  inducements  for  the  midwinter 
tourists  and  chronic  invalids  from  the  North  that  a  brief 
description  of  my  recent  three  weeks'  tour  may  interest  the 
many  readers  of  American  Medicine.  It  is  a  strange  but  pleas- 
ing experience  to  leave  icebound  Chicago  and  in  less  than  a 
week  find  yourself  in  a  new  country,  among  strange  people 
and  surrounded  by  the  luxviriance  of  a  tropical  climate.  It  is 
on  an  occasion  like  this  that  we  are  reminded  of  our  school- 
boy days  when  we  were  made  to  study  geography  and  stock 
our  youthful  imaginative  minds  with  the  location  of  distant 
countries,  their  people,  their  climate,  products  of  the  soil,., 
manufactories,  and  workshops.  It  is  a  source  of  great  gratifi-- 
cation  to  look  at  the  dizzy  height  of  the  gigantic  palms,  to  pick.; 
from  the  shrubby  nutmeg  tree  its  aromatic  fruit  of  the  color  of 
gold,  and  from  the  pepper  vine  the  grape-like  clusters  of 
pungent  green-yellow  berries,  and  to  attack  the  bark  of  the 
cinnamon  tree  with  a  pocket-knife  to  satisfy  yourself  that  you 
have  found  the  real  article  remembered  so  well  by  many  as  one 
of  the  ingredients  of  the  favorite  delicate  dishes  of  childhood 
days.  Spend  a  short  midwinter  vacation  in  the  West  Indies, 
as  I  did,  and  you  will  experience  the  same  delight, 
and  will  return  to  your  arduous  duties,  as  I  did,  with  pleasant, 
dreams  of  what  the  special  senses  enjoyed  and  in  a  better- 
humor  to  bear  the  burdens  of  the  daily  routine  toil.  Besides; 
admiring  nature's  exquisite  beauties  which  only  a  tropical  soil;^ 
can  build  and  a  tropical  sun  can  paint  the  medical  visitor  to> 


the  West  Indies  is  most  interested  in  the  shady  side-  of  life  in 
the  tropics— tropical  diseases.  With  our  present  methods  of 
rapid  navigation  a  physician  living  east  of  the  Rocky  Moun- 
tains can  visit  the  most  interesting  and  important  islands  of 
the  West  Indies  and  obtain  a  fair  knowledge  of  their  people, 
natural  resources  and  prevailing  diseases  and  return  in  four 
weeks  well  satisfied  with  w^hat  he  has  seen  and  learned.  The 
trip  during  which  the  following  observations  were  made 
extended  from  January  15  to  February  5,  1903,  with  New  York 
and  the  island  of  Martinique  as  opposite  points.  The  passen- 
gers on  the  "  Kaiserin  Maria  Theresa,"  of  the  North  German 
Lloyd,  left  New  York  wrapped  in  furs  and  the  heaviest  over- 
coats, and  many  demands  were  made  of  the  stewards  for  addi- 
tional blankets  to  fight  the  cold  in  the  chilly  staterooms  when 
the  shivering  passengers  retired  for  the  night.  This  source  of 
discomfort  did  not  last  long  as  the  great  ship  under  full  steam 
made  a  bee  line  for  the  equator,  evidently  anxious  to  relieve 
her  human  freight  of  the  cumbersome  winter  clothing.  On  the 
third  day  out  a  general  overhauling  of  the  contents  of  the 
steamer  trunks  in  search  for  lighter  clothing  became  the  main 
occupation  of  the  passengers.  Silk  and  linen  took  the  place  of 
wool  and  fur,  and  white  and  yellow  became  strong  rivals  of 
the  sombre  black,  brown  and  gray  of  the  wearing  apparel,  a 
change  from  which  caps,  hats  and  shoes  were  not  exempt. 
In  a  very  few  days  the  dome  of  gray  threatening  clouds  disap- 
peared as  by  magic,  and  the  lifting  of  this  heavy  impenetrable 
curtain  by  invisible  hands  exposed  to  the  unobstructed  vision 
the  azure  blue  boundless  sky  of  the  tropics,  decorated  during 
the  day  by  the  warm  sun  of  the  South  which  approached  nearer 
every  day  with  ever  increasing  fervor,  and  by  night  by  the 
pale  crescent-shaped  moon  and  countless  luminous  stars. 
Before  we  were  aware  of  the  distance  we  had  traveled  land  was 
sighted,  and  on  the  morning  of  January  19  we  reached  our  first 
destination,  the  harbor  of  Charlotte  Amalie. 

m.  Thomas.— This  is  one  of  the  three  islands  in  the  West 
Indies  belonging  to  Denmark.  It  is  an  important  coaling 
station  for  merchant  vessels  from  the  most  remote  parts  of 
the  world.  More  than  half  of  its  small  population  live  in 
Charlotte  Amalie,  the  seat  of  the  colonial  government.  A  small 
military  force  is  located  here.  The  principal  revenue  is  derived 
from  the  export  of  bayrum,  which  is  noted  for  its  superior 
quality  and  cheapness.  The  soil  is  unproductive  and  the  negro 
population  miserably  poor.  The  government  oflicials,  the 
military,  and  a  few  business  men  make  up  the  small  body  of 
white  inhabitants.  Two  Danish  doctors  attend  to  the  needs  of 
the  sick.  The  government  is  obliged  to  do  what  it  can  for  the 
sick  poor. 


JCommune  Hospitalet. — This  hospital  can  accommodate  115 
patients  when  it  is  taxed  to  its  utmost  capacity.    It  is  arranged 
in  the  form  of  an  open  square,  and  consists  of  one-story  barracks 
divided  into  small  wards  for  six  to  eight  patients  ;  all  of  these 
wards  open  on  the  square.    On  the  left  at  the  entrance  of  the 
square  is  the  building  for  men,  on  the  right  for  women,  and  in 
the  rear  is  a  one  story  frame  building  for  the  insane.    The  hos- 
pital   is    furnished    in  a  most    primitive    way,  and  the  filth 
appeals  both  to  the  eye  and  nose.    We  found  here  the  usual 
varietyof  diseases  which  ordinarily  prevail  here,  syphilis,  rheu- 
matism, ulcer  of  leg,  bronchitis,  endocarditis,  and  myocarditis, 
and  a  number  of  cases  of  elephantiasis.    Only  one  of  the  insane 
was  locked  in  his  room,  the  remaining  patients  were  either  in 
their  open  rooms  or  wandering  about  in  the  yard.    I  was  inter- 
ested to  ascertain  who  was  responsible  for  the  filthy  condition 
of  the  institution.  After  a  somewhat  prolonged  search  we  found 
the  female  nurse  who  had  charge  of  the  patients  who  belonged 
to  her  sex.    She  was  a  colored  woman  of  doubtful  age,  clad  in  a 
dirty  calico  dress,  her  dusky  face  made  more  so  under  the 
shadow  of  a  large  straw  hat  with  drooping  broad  rim  that  evi- 
dently had  done  service  for  many  a  season.    To  the  inquiry 
where  she  had  received  her  training,  she  made  no  direct  reply. 
The  only  argument  she  made  as  to  her  proficiency  as  a  nurse 
was  that  she  was  the  mother  of  seven  children  and  thought 
that  that  kind  of  practical  training  ought  to  suffice  to  prepare 
her  for  her  vocation  in  life.    With  this  kind  of  training  she 
entered  the  institution  17  years  ago  and  has  held  her  place  ever 
since.    She  was  particularly  anxious  to  impress  upon  us  the 
wonderful  results  of  her  extensive  obstetric  work.    The  con- 
valescent women  give  her  assistance  in  the  performance  of  the 
more  arduous  and  menial  part  of  her  work.    The  nursing  on 
the  opposite  side  of  the  square  made  no  better  showing.    A 
negro,  who  looked  like  an  ordinary  day  laborer,  served  in  the 
same  capacity  here.    A  vest  that  once  was  white  and  a  clumsy 
pair  of  cowhide  shoes  distinguished  him  from  his  subordinates, 
so  far  as  external  appearances  were  concerned.  The  doctor  who 
is  in  charge  of  this  hospital  is  said  to  be  a  very  busy  man,  but 
he  never  fails  to  take  his  siesta  between  high  noon  and  3  p.m., 
a  time  he  claims  for  himself,  and  during  which  when  called 
upon  he  sends  his  compliments  by  a  dark-skinned  bonne  of  the 
island,  that  is  if  she  can  muster  enough  courage  to  disturb  her 
master's  nap  by  conveying  a  message  to  him  during  that  time 
of   the  day.    The  poverty  of   the  island  may  offer  a  partial 
excuse  for  the  way  in  which  this  hospital  is  conducted,  but  it 
is  high  time  that  the  general  government,  so  long  as  it  persists 
in  holding  it  as  a  colony,  should  look  into  this  part  of  the  man- 
agement of  its  black  subjects. 


'St.  Kitts,  a  small  speck  in  the  mighty  ocean,  is  one  of  the 
numberless  colonies  of  England,  as  well  as  one  of  its  oldest.  It 
is  reached  from  St.  Thomas  in  a  few  hours  by  steamer.  It  does 
not  take  long  for  the  visitor  to  learn  that  he  is  on  British  soil. 
English  is  the  language  of  this  island.  The  native  policemen 
are  splendid  specimens  of  the  colored  race,  well  uniformed  and 
disciplined,  clean,  courteous,  and  faithful  in  the  execution  of 
their  duties.  The  clean  streets  and  splendid  country  roads  are 
a  good  evidence  of  a  modern  progressive  government.  St.  Kitts 
has  a  population  of  about  30,000,  of  which  the  negroes  furnish 
the  bulk.  Basse  Terre  is  the  only  city  of  any  size.  It  is  the 
seat  of  the  local  government  and  important  charitable  institu- 
tions. Like  nearly  all  of  the  West  Indies,  the  interior  of  the 
island  is  mountainous.  Our  country  is  represented  here  by 
Consul  Dr.  Haven,  a  graduate  of  Rush  Medical  College,  who 
practised  his  profession  for  many  years  with  great  success  in 
Chicago,  and  who  accepted  his  present  position  to  recuperate  his 
health  by  a  change  of  climate.  To  him  we  are  indebted  for 
many  courtesies. 

Lazaretto  or  Leper  Asylum.— l^e-prof^j  is  found  in  all  of 
the  West  Indies,  but  is  quite  prevalent  in  St.  Kitts.  The  Laza- 
retto is  located  on  a  high  elevation  by  the  seashore  and  near  the 
base  of  Brimstone  Hill,  with  the  remains  of  an  old  fortifica- 
tion upon  it,  which  was  abandoned  36  years  ago.  The  Lazaretto 
is  connected  with  the  city  by  a  magnificent  macadamized  road 
which  follows  the  seashore  and  passes  through  a  number  of 
quaint  negro  villages,  the  landmarks  of  former  large  sugar 
plantations.  The  asylum  buildings  are  well  adapted  for  the 
purpose  for  which  they  were  intended.  An  open  space  between 
them  has  been  transformed  into  a  charming  flower  garden, 
intersected  by  beautiful  gravel  walks.  A  tract  of  several  acres 
of  land  belongs  to  the  institution,  but  the  soil  is  so  poor  that 
nothing  has  been  done  in  the  way  of  cultivating  it.  The  colony 
was  founded  10  years  ago,  and  has  been  managed  ever  since  by 
Dr.  John  Foreman,  who  takes  a  deep  interest  in  its  welfare. 
Absolute  segregation  does  not  exist  in  any  of  the  islands.  In 
St.  Kitts  and  the  rest  of  the  West  Indian  British  colonies 
ample  provision  is  made  for  the  indigent  lepers.  The  law 
requires  that  lepers  should  not  pursue  any  vocation 
which  would  be  likely  to  spread  the  disease,  such  as  the  hand- 
ling of  foodstuff  and  clothing.  If  a  leper  is  found  begging  or 
engaged  in  a  business  or  trade  calculated  to  disseminate  the 
disease  he  is  arrested,  convicted  and  sent  to  the  asylum  for 
treatment  and  isolation.  At  present  there  are  72  lepers  in  the 
Lazaretto,  the  youngest  a  little  bey  of  6.  The  macular  and 
tuberculous  variety  are  about  equally  represented,  as  well  as 
the  sexes.    All  of  the  i)atients  are  negroes,  with  the  exception 


of  two  Portuguese  women.    The  treatment  is  palliative  and 
symptomatic. 

Cunningham  ITospitn I. —This  is  the  government  hospital  of 
the  city  of  St.  Kitts  and  commemorates  the  name  of  a  former 


Acute  exfoliative  dermatitis  (St.  John' 


Governor  of  the  island.  It  has  a  capacity  for  about  100  patients. 
The  buildings  are  two-story  barracks,  the  lower  of  solid 
masonry,  the  upper  of  wood.  The  wards  are  well  lighted  and 
plainly  but  comfortably  furnished.  Dr.  W.  J.  Brauch  is  the 
medical  officer  in  charge.    He  is  assisted  by  two  graduate  col- 


6 

ored  pharmacists.  I  found  here  two  cases  of  amputation  of  the 
leg  for  elephantiasis,  the  operation  having  been  made  necessary 
by  extensive  ulceration.  The  patients  were  doing  well,  but  the 
wounds  failed  to  heal  by  primary  intention.  The  colored 
female  nurses  under  the  direction  of  a  trained  English  nurse 
take  care  of  the  sick,  and  the  general  cleanliness  which  prevailed 
here  spoke  well  for  their  efficiency  and  industry. 

,St.  Joh7is—We  landed  at  Antigua,  St.  Johns,  January  21, 
and  lost  no  time  in  looking  up  the  medical  aspects  of  the  island 
city.  A  visit  to  the  ancient  cathedral  reminded  us  that  the 
public  is  sometimes  appreciative  of  the  services  of  physicians 
after  they  have  completed  their  unselfish  career  and  have  gone 
to  their  reward.  On  a  marble  tablet  on  the  wall  on  the  right 
side  of  the  main  entrance  I  found  the  following  inscription: 

To 

The  Memory  of 

Robert  Peddie, 

Surgeon, 

Native  of  Kelso  in  Roxburghshire,  N.  B., 

Who  died  in  this  island 

On  the  XVI  of  November,  A.D.  MDCCCXLI, 

At  the  age  of  XLI  years. 

This  Tablet 

Is  consecrated  by  the  sympathies  of 

A  few  of  his  friends. 

In  life  they  esteemed  him 

As  well  for 

His  faithful  discharge  of  his  duties 

As  a  member  of  the  Legislature 

As  for 

Exemplary  conduct  in  all  the  Relations 

Of  Professional  and  Domestic  Intercourse. 

And  now  that  he  is  departed, 

They  desire  to  record  their  feelings 

Of  sorrow  and  respect 

That  these  may  not  pass  away  with 

Their  own  fleeting  existence. 

The  wording  of  the  above  tribute  reflects  the  feelings  of 
esteem  and  veneration  for  the  life  work  of  an  exemplary  mem- 
ber of  the  medical  profession. 

St.  Johns  has  been  impoverished  since  the  depression  of  the 
sugar-cane  industry.  The  streets  of  Antigua,  the  capital,  are 
thronged  with  beggars  w^ho  are  noted  for  their  aggressiveness 
when  visitors  make  their  appearance.  Outstretched  black 
hands  and  the  plaintive  "  give  me  a  penny  "  constantly  menace 
the  peace  of  mind  of  the  stranger  on  the  streets.    If  the  hungry 


i 


crowd  becomes  too  large  it  is  sometimes  necessary  to  look  for 
a  policeman  for  relief  or  enter  or  seek  peace  and  rest  in  some 
public  establishment.  Malaria  is  quite  common  in  St.  Johns. 
On  the  other  hand,  typhoid  is  quite  rare. 

Vaccination  is  enforced  by  the  Board  of  Health,  conse- 
quently the  mass  of  the  people  is  protected  against  smallpox. 
The  entire  population  is  saturated  with  syphilis.  The  disease 
has  existed  for  such  a  long  time,  and  is  so  common,  that  it  has 
lost  much  of  its  virulence.  Some  idea  may  be  formed  of  the 
prevalence  of  this  scourge  of  the  colored  race  from  the  fact  that 
150  pounds  of  potassium  iodid  are  consumed  in  the  hospital 
annually.  Tuberculosis  here,  like  elsewhere  in  the  West 
Indies,  has  a  firm  hold  on  the  black  race.  The  insane  asylum 
is  located  on  an  island  in  the  harbor,  formerly  a  strong  forti- 
fication. The  leper  colony  is  located  on  a  high  ridge  overlook- 
ing the  harbor,  and  numbers  at  the  present  time  40  inmates, 
all  colored. 

Holderton  Hospital. — This  is  the  only  hospital  on  the  island, 
and  can  accommodate  200  patients.  It  bears  the  name  of  a 
deceased  rector  of  the  ancient  cathedral.  It  is  in  charge  of  Dr. 
Frederick  L.  Norris,  a  young  and  most  capable  physician.  The 
wards  are  airy,  neat  and  fairly  well  furnished.  The  buildings 
occupy  the  eminence  of  a  hill  behind  the  city,  and  the  ample 
grounds  are  well  laid  out  and  ornamented  with  tropical  trees, 
shrubs  and  flowering  plants.  From  here  a  beautiful  view  of 
the  city  and  harbor,  as  well  as  distant  mountains,  can  be 
obtained. 

Elephayitiasis  in  /St.  Johns, — The  visitor  need  not  go  to  the 
hospital  to  see  this  disease,  it  is  constantly  seen  in  all  its  stages 
in  the  streets.  The  bare  legs  displayed  by  men,  women  and 
children  make  it  possible  to  study  this  disease  in  the  streets 
any  time  of  the  day.  Through  the  courtesy  of  Dr.  Norris  I  had 
an  opportunity  to  examine  72  cases  of  elephantiasis.  20  in  the 
hospital  and  52  in  the  poorhouse.  Among  this  number  were 
two  cases  of  scrotal  elephantiasis.  In  one  of  them  a  negro,  aged 
about  30,  the  disease  involved  first  the  right  leg,  and  two  years 
ago  it  extended  to  the  scrotum,  which  at  the  present  time  has 
reached  the  size  of  the  head  of  an  adult  and  is  complicated  by 
enormous  enlargement  of  the  penis.  In  the  second  case,  an  old 
negro,  the  disease  was  limited  to  the  scrotum  and  had  reached 
about  the  same  dimensions.  In  the  poorhouse,  50%  of  the 
inmates  were  disabled  by  this  disease.  Dr.  Norris  is  averse  to 
operative  interference  in  such  cases,  as  the  disease  as  a  rule  has 
impaired  the  general  health  of  the  patients  to  an  extent  as  to 
interfere  seriously  with  the  satisfactory  healing  of  wounds  and 
subsequent  restoration  of  the  general  health  of  the  patient. 
The  vulva  is  very  seldom  affected  by  this  disease,  otherwise 


women  are  as  susceptible  to  it  as  men.  The  nursing  here,  like 
in  all  the  British  possessions  of  the  West  Indies,  is  in  charge  of 
a  graduate  English  nurse,  who  at  the  same  time  serves  as 
matron.  Colored  girls  of  desirable  age  enter  the  hospital  and 
without  any  special  instruction  or  training  begin  their  work. 
They  become  very  useful  hospital  servants  but  lack  the  high 
qualifications  of  our  nurses.  They  receive  from  four  to  eight 
dollars  a  month  for  their  services,  according  to  the  degree  of 
efficiency  and  experience  in  their  work.  The  poorhouse  and 
prison  are  near  the  hospital,  the  former  on  the  same  grounds. 

An  Innocent  Prisoner.— XJnder  the  guidance  of  the  prison 
captain.aud  Dr.  Norris  we  visited  the  prison.  The  prisons  in 
all  English  colonies  are  models  of  their  kind,  and  the  Antigua 
prison  proved  no  exception.  The  discipline  is  perfect,  and  the 
prisoners  are  made  to  pay  the  penalty  of  their  offense  against 
the  law  by  hard  manual  labor  that  requires  no  skill,  princi- 
pally crushing  stone.  In  one  part  of  the  prison  rough  coffins 
are  made  for  the  Vjurial  of  the  poor.  The  execution  chamber  in 
the  prison  building  has  been  idle  for  more  than  two  years,  but 
the  machinery  for  hanging  is  kept  in  good  repair.  Corporal 
punishment  is  only  resorted  to  in  the  most  obstinate  and 
refractory  casas,  and  consists  usually  in  the  use  of  the  lash  or 
four  hours  in  the  treadmill.  The  women  contingent  is  larger 
here  than  in  most  prisons.  Washing  is  their  principal  employ- 
ment. In  the  female  department  we  found  a  coal-black  baby 
boy  only  a  few  days  old  curled  up  on  a  floor-mat  on  the  stone 
floor.  This  little  convict  was  certainly  incarcerated  without 
any  cause  for  which  he  could  be  held  legally  responsible.  His 
mother  was  serving  her  sentence  for  a  petty  ofl"ense,  and  before 
her  time  expired  one  more  inmate  was  added  to  the  prison  roll. 
This  instance  illustrates  well  that  the  innocent  have  often  to 
sufter  the  crimes  of  the  guilty.  May  this  infant  prisoner  never 
know  where  he  was  born  ! 

Hospitals  of  the  West  Indies  as  Postgraduate  Institutions 
for  the  Study  of  Tropical  Diseases. — It  is  a  great  pity  that  the 
medical  officers  of  the  hospitals  of  the  West  Indies  have  neither 
the  time  nor  the  appliances  for  the  scientific  investigation  of 
the  many  as  yet  obscure  tropical  diseases  they  are  called  upon 
to  treat.  The  material  is  simply  enormous,  and  could  be  readily 
made  available  by  our  young  graduates  in  medicine  and  by 
prospective  health  officers.  These  are  the  places  to  which  the 
attention  of  our  foremost  medical  schools  should  be  directed. 
Some  of  the  scholarships  should  be  devoted  to  the  study  of 
tropical  diseases  in  these  colonies.  I  am  sure  every  hospital 
would  throw  open  its  doors  widely  to  students,  provided  the 
investigations  would  be  made  without  increasing  the  financial 
outlay.   "I  became  so  deeply  impressed  with  the  great  oppor- 


9 


tunities  that  I  determined  to  use  all  my  influence  to  have 
Rush  Medical  College  take  an  initiative  step  in  this  direction, 
with  the  hope  that  other  institutions  would  follow  the  example, 
so  that  in  a  few  years  a  competent  bacteriologist  might  be  found 
in  all  of  the  hospitals.  There  is  no  better  place  for  the  study  of 
elephantiasis  than  St.  John's ;  St.  Vincent,  for  ankylostoma 
duodeualis,  and  St.  Kitts  for  leprosy,  and  all  of  these  islands  for 
acute  and  chronic  intestinal  diseases. 

Mar ti7iique.— This  island,  under  French  rule,  was  the  prin- 
cipal objective  point  of  my  short  midwinter  vacation.  It  is  the 
most  picturesque  of  all  the  West  Indies,  and  the  most  widely 
known  since  the  last  eruption  of  Mount  Pelee,  which  com- 
pletely destroyed  St.  Pierre  and  nearly  one-third  of  the  entire 
population  of  the  island.  This  island  was  discovered  by 
Columbus,  June  15, 1502.  He  landed  at  Corbet,  near  the  present 
ruins  of  the  illfated  city,  St.  Pierre. 

Fort  de  France  is  the  capital  of  Martinique  and  has  at 
present  a  population  of  nearly  40,000.  Very  few  of  the  original 
race,  the  Caribs,  remain.  Like  all  primitive  peoples  they  have 
disappeared  by  the  ravages  of  the  diseases  brought  to  their 
beautiful  island  by  the  invaders.  They  struggled  long  and 
fiercely  for  their  rightful  possession  but  finally  had  to  yield  to 
the  inevitable.  The  negroes  have  increased  to  an  alarming 
extent,  and  since  the  sugar  industry  has  been  waning  the 
government  is  seriously  taxed  in  taking  care  of  the  poor.  The 
city  is  well  drained  and  lighted  and  has  excellent  streets.  The 
whites  are  few  and  by  no  means  in  a  cheerful  mood  owing  to 
financial  reverses  which  have  occurred  in  the  past  and  which 
are  in  store  for  them  in  the  future.  Most  of  the  houses  show 
indications  of  decay  and  very  few  buildings  are  in  process  of 
erection.  The  hotels  are  primitive  and  the  table  still  more  so. 
Meat  is  poor  and  scarce.  Fish  is  plentiful  and  in  great  variety, 
but  cannot  compare  in  quality  with  those  of  our  northern 
waters.  The  negroes  subsist  largely  on  bread  fruit,  guavas, 
mangoes,  cocoanuts,  bananas,  plantains  and  other  cheap  trop- 
ical fruits.  A  small  military  force  occupies  the  garrison.  The 
policemen  are  negroes  under  command  of  French  officers. 
The  prevailing  language  is  French,  which  by  the  lower  class  of 
people  has  been  changed  into  a  patois  unintelligible  to  the 
Parisian.  The  military  hospital  is  an  elegant  red  brick  struc- 
ture, well  equipped,  a  credit  to  the  military  branch  of  the  gov- 
ernment. 

Hopital  Civil.— This  is  the  general  hospital,  open  to  the 
sick  from  the  entire  island.  It  is  situated  outside  of  the  city 
limits  on  a  mountain  side  several  hundred  feet  above  the  level 
of  the  sea.  It  was  built  five  years  ago  at  great  expense  and  has 
room  for  250  patients.  The  ample  grounds  are  artistically  laid  out 


10 

and  beautified  in  a  way  only  possible  in  a  tropical  country. 
Pure  water  is  supplied  from  mountain  springs  in  abundance 
and  all  of  the  buildings  are  lighted  by  electricity.  Seven  two- 
story  pavilions  face  the  valley  in  a  straight  line,  all  of  these 
connected  by  excellent  sidewalks.  The  lower  stories  are  made 
of  solid  stone  walls,  the  upper  of  wood  painted  white.  The  red 
roofs  of  tiling  furnish  a  pleasing  contrast  with  the  exquisite 
verdure  of  the  mountain  side  behind  and  snowy  whiteness  of 
the  walls  beneath.  The  nursing  is  in  charge  of  nine  Sisters  of 
Charity,  which  in  itself  would  account  satisfactorily  for  the 
scrupulous  cleanliness  inside  and  outside  of  the  buildings.  The 
operating-room  is  a  separate  frame  building  octagonal  in  shape. 
The  instrument  supply  is  a  very  limited  one,  which  means  that 
no  unnecessary  operations  are  performed^  I  found  here  again 
many  cases  of  elephantiasis ;  the  affected  leg  of  one  of  the 
patients  must  have  weighed  at  least  75  pounds.  The  enormous 
weight  of  the  limb  required  much  effort  on  the  part  of  the 
patient  when  he  attempted  to  walk.  Dr.  Bouvier  is  the 
medical  director.    He  is  assisted  by  a  resident  interne. 

The  Ruins  of  St.  Pierre. — The  former  city  of  St.  Pierre,  now 
in  ruins,  is  by  the  coast  line  20  miles  distant  from  Fort  de 
France.  Before  its  destruction  by  the  volcanic  eruption  of  Mount 
Pelee  it  was  a  thriving  city  of  about  36,000  inhabitants.  Mount 
Pelee  is  4,500  feet  high,  and  separated  from  the  ruins  by  a  low 
mountain  ridge  and  a  small  river.  The  destruction  of  the  city 
was  as  sudden  as  it  w^as  complete.  The  terrible  catastrophe 
occurred  at  5.30a.m.,  May  8, 1902.  The  eruption  was  in  reality  an 
explosion  of  the  most  terrible  kind.  Before  the  explosion  the 
water  from  the  little  lake  which  occupied  the  basin  of  the 
extinct  crater  disappeared.  It  is  claimed  that  the  entrance  of 
such  a  large  volume  of  water  into  the  subterranean  furnace  was 
the  principal  cause  of  the  explosion ;  at  any  rate  it  is  certain  that 
the  hydrogen  gas  which  escaped  when  the  explosion  occurred 
filled  the  entire  valley  occupied  by  the  city,  ignited  and 
destroyed  everything  living  and  ignitable  within  reach.  The 
explosion  tore  open  the  mountain  below  the  crater  on  the  side 
of  the  city  and  the  gas  escaped  with  such  tremendous  force  that 
the  largest  trees  were  uprooted  and  the  most  substantial  build- 
ings torn  down.  The  positions  of  the  prostrate  trees  and  the 
torn  down  walls  are  everywhere  the  same — away  from  the 
mountain.  The  death  of  the  people  and  the  destruction  of  the 
city  came  with  an  awful  suddenness.  In  less  than  five  minutes 
the  furious  mountain  had  accomplished  its  deadly  work.  Not 
a  house  remains,  and  of  the  nearly  40,000  people  only  one  Avas 
saved.  What  was  formerly  the  rival  of  Fort  de  France  is 
wiped  out  of  existence.  The  recent  ruins  present  today  an  awe- 
inspiring  picture.    Many  of    the  houses  are  leveled    to   the 


11 

ground.  The  stately  churches  are  mere  piles  of  brick  and 
stone.  The  giants  of  the  forests,  charred  and  mangled,  obstruct 
the  vacant  streets.  All  signs  of  animal  life  have  disappeared. 
The  ruins  are  really  a  great  cemetery  in  which  more  than 
30,000  bodies  remain.  More  than  6,000  bodies  have  been  found, 
and  were  either  buried  or  cremated  ;  the  others  are  buried  under- 
neath the  debris  of  the  ruins  and  a  layer  of  lava  mud  of  varying 
thicknesses.  It  is  said  that  no  man  is  so  wicked  as  to  be 
entirely  devoid  of  virtue.  The  same  may  be  said  of  Mount 
Pelee.  What  she  did  in  a  rage  of  anger  she  did  quickly. 
Probably  not  a  single  one  of  the  victims  svifFered  the  pangs  of 
death  for  more  than  five  minutes.  The  deadly  gases,  the  burn- 
ing atmosphere  and  the  force  of  the  explosion  killed  almost 
instantly  every  living  thing  within  reach.  Then  the  volcano 
undertook  the  task  of  the  undertaker  by  throwing  out  a  rain  of 
soft  mud  until  most  of  the  corpses  were  out  of  sight.  The 
former  city  is  now  a  deserted  ruin.  Not  a  soul  lives  there.  At 
the  time  of  our  visit  a  number  of  negro  women  were  picking 
up  tiles  along  the  beach.  A  few  negroes  were  busy  here  and 
there  with  picks  and  spades  in  search  for  buried  treasures  and 
relics  of  the  disaster.  Bones  and  whole  skeletons  are  being 
uncovered  daily  by  the  drenching  rains  washing  away  the 
thin  layer  of  mud  under  which  at  first  they  were  buried.  Not 
a  roof  remains,  and  many  of  the  narrow  streets  are  com- 
pletely obstructed  by  the  debris  of  the  ruins  and  the  volcanic 
mud.  St.  Pierre  will  live  in  history,  but  will  never  be  rebuilt 
on  its  present  site.  On  the  day  of  our  visit  the  summit  of 
Mount  Pelee  was  wrapped  in  mourning,  but  through  the 
dense  veil  of  clouds  ascending  columns  of  steam  could  be  seen, 
a  warning  that  the  volcano  so  far  has  refused  to  rest.  The  next 
day  an  explosion  blew  off  the  top  of  the  mountain.  The  force 
of  the  explosion  and  the  fire  which  destroyed  the  city  extended 
far  beyond  the  limits  of  the  city.  In  the  direction  of  the  explo- 
sion not  a  single  living  tree  could  be  seen.  It  was  in  the  neigh- 
borhood of  the  destroyed  city,  near  the  limits  of  the  sea  of  fire, 
that  many  people  were  injured  and  suffered  from  more  or  less 
extensive  burns.  Of  these,  250  were  sent  to  the  Civil  Hospital 
at  Fort  de  France.  I  had  an  opportunity  to  examine  a  few  of 
these  patients  that  remained  at  the  time  of  my  visit,  recovering 
slowly  from  the  effects  of  burns. 

A  MiraculouH  Mscape.— Only  one  of  the  inhabitants  of  St. 
Pierre  escaped.  He  was  a  prisoner,  and  was  not  discovered  in 
his  prison  cell  until  four  days  after  the  disaster.  All  the 
remaining  prisoners  were  killed.  The  prisoner  who  found  his 
freedom  in  such  a  miraculous  way  is  a  negro  aged  about  35. 
He  has  suddenly  risen  in  distinction.  He  is  now  a  successful 
beggar  in  Fort  de  France.    I  met  him  in  a  little  cigar  store  and 


12 


was  successfully  appealed  to  for  a  small  contribution,  in  con- 
sideration of  which  he  willingly  exhibited  large  scars  over  the 
left  shoulder  and  same  side  of  chest,  following  the  healing  of  an 
extensive  burn.  Later  he  came  on  board  the  ship  for  exhibi- 
tion and  realized  ^20,  probably  more  money  than  he  ever 
handled  before. 

St.  Vince7it.—This  little  island  possession  of  England  has 
come  into  notoriety  by  the  volcanic  eruption  of  its  highest 
volcanic  mountain  (3,000  feet),  La  Souffri^re,  which  became 
active  at  the  same  time  with  the  distant  Mount  Pelee.  Two 
thousand  lives  were  lost  and  a  whole  village  destroyed.  Ashes 
were  blown  as  far  as  Barbados,  over  100  miles  away.  Kings- 
town is  the  capital  city.  It  has  9,000  inhabitants,  with  few 
exceptions  negroes.  The  botanical  garden  is  one  of  the  finest 
in  the  world.  It  was  established  in  1764,  the  first  in  the  West 
Indies.  The  visitor  will  find  here  the  greatest  variety  of  palm 
trees,  indigenous  and  from  foreign  tropical  countries,  cacao, 
cinnamon  and  nutmeg  trees,  and  the  pepper  vine. 

ColonioA  Hospital.— This  is  the  principal  hospital  of  the 
island  and  has  room  for  80  patients.  The  grounds  upon  which 
the  hospital  is  built  present  a  truly  tropical  appearance.  The 
tov;ering  gigantic  palms,  floAvering  shrubs  and  ferns,  make  a 
most  attractive  foreground.  Like  all  of  the  West  Indian  hos- 
pitals it  is  built  on  the  barrack  plan.  The  pavilions  are  two 
stories  high,  the  lower  of  stone,  the  upper  of  wood.  The  upper 
story  projects  about  eight  feet  beyond  the  lower.  The  furni- 
ture is  of  the  plainest  kind  but  answers  all  of  the  existing 
requirements.  The  wards  are  kept  clean  and  in  excellent 
order.  An  English  trained  nurse  is  the  matron  and  super- 
vises the  work  of  the  colored  nurses.  Dr.  C.  W.  Branch  is  the 
attending  physician.  He  is  a  graduate  of  Edinburgh  and  is  an 
earnest,  enthusiastic  and  progressive  man.  He  and  another 
physician  take  care  of  all  the  sick  in  the  city  and  surrounding 
country. 

Ankylostoma  Duodenalis  in  St.  Fmcen^.— Uncinariasis 
(Ankylostomiasis)  is  very  common  in  all  the  West  Indies, 
but  particularly  so  in  St.  Vincent.  Dr.  Brauch  believes  that 
at  least  one-third  of  the  entire  population  is  affected  by  this 
disease.  The  principal  symptom  is  a  gradually  increasing 
anemia.  Ultimately  fatty  degeneration  of  the  liver  invariably 
takes  place.  During  the  early  stages  of  the  parasitic  invasion 
the  disease  is  often  overlooked.  Careful  examination  of  the 
stools  must  be  relied  upon  in  making  a  positive  diagnosis. 
In  one  year  Dr.  Brauch  treated  120  patients.  His  treatment 
consists  in  the  administration  of  large  doses  of  thymol.  To 
an  adult  he  never  administers  less  than  8  grams  (120  grains) 
of  the  drug  divided  in  four  equal  parts,  which  are  adminis- 


18 

tered  in  capsules  one  hour  apart,  beginning  early  in  the 
morning.  In  tlie  evening  following  castor-oil  is  given  in 
sufficiently  large  doses  to  produce  free  catharsis.  The  reputa- 
tion of  thymol  in  the  treatment  of  this  disease  has  been  well 
established,  not  only  here  but  in  many  other  hospitals  in 
the  tropics.  Sometimes  the  treatment  has  to  be  repeated. 
Toxic  symptoms  are  not  often  observed,  but  should  they 
appear  speedy  elimination  of  the  thymol  by  early  and  free 
catharsis  will  soon  relieve  the  unpleasant  symptoms. 

Kingstown,  St.  Vincent,  January  24, 1903. 


3 

and  counterirritations  by  the  use  of  the  actual  cautery.  The 
entire  number  of  patients  for  the  year  amounted  to  3,799. 
Among  the  most  noteworthy  diseases  were  typhoid,  malaria, 
tuberculosis,  and  venereal  affections,  and  their  complications. 
The  report  alludes  to  the  typhoid  fever  patients  as  follows: 
"  There  were  28  cases  of  this  disease  admitted  with  12 
deaths,  a  very  high  deathi-ate  no  doubt;  but  nearly  all  of  the 
fatal  cases  were  admitted  in  a  very  advanced  stage  of  the  dis- 
ease, indeed  little  or  nothing  could  be  done  for  them."  Malarial 
fever  was  most  prevalent  daring  the  last  five  months  of  the 
year.  The  mortality  from  this  disease  was  very  small.  Of 
1,226  cases  18  proved  fatal.  The  venereal  cases  numbered  206 
and  were  classified  as  follow :  Syphilis,  33 ;  gonorrhea,  90 ; 
chancroid,  83.  The  hope  is  expressed  that  the  disease  is  on  the 
decline.  The  five  cases  of  tetanus  proved  fatal  without  an 
exception.  Only  one  case  of  yellow  fever  is  recorded  and  this 
patient  died.  In  two  amputations  for  elephantiasis  of  the  leg 
the  patients  recovered.  Elephantiasis  and  ankylostoma  are 
rare  affections  here  as  compared  with  some  of  the  islands 
further  east  and  south. 

Cuba.— The  war  with  Spain  has  made  us  more  familiar  with 
Cuba  than  any  other  island  in  the  West  Indies.  This  event  has 
given  us  ample  opportunity  to  become  better  acquainted  with 
its  people  and  the  diseases  which  afflict  them.  Our  invading 
army  reached  the  island  at  a  time  when  the  climate  was  most 
dangerous  and  the  acute  infectious  diseases  most  prevalent.  In 
a  few  weeks  we  lost  nearly  one-half  of  the  fighting  force  by  dis- 
ease. The  number  killed  outright  by  bullets  was  small  compared 
with  the  loss  from  disease.  The  Spaniards  passed  through  the 
same  trying  experience.  It  is  well  known  that  the  Spanish  army 
lost  50%  of  its  fighting  strength  from  the  same  cause  in  two 
months  after  landing  in  Cuba.  The  Spanish  surgeon  I  met 
inside  of  the  lines  of  the  enemy,  a  few  days  before  the  surrender 
of  Santiago,  where  we  delivered  to  him,  under  a  flag  of  truce,  16 
wounded  Spanish  prisoners,  informed  us  that  when  his  part  of 
the  army  reached  Cuba  the  men  were  all  in  good  health,  and 
that  then  many  were  sick,  and  none  well.  He  drew  a  sad 
picture  of  how  their  ranks  were  decimated  by  yellow  fever, 
malaria,  and  dysentery.  During  the  entire  insurrection  Cuba 
was  at  no  time  entirely  free  from  yellow  fever,  and  malaria  is 
present  more  or  less  in  most  of  the  valleys  and  lowlands  of  the 
coast.  Many  of  our  soldiers  were  infected  with  typhoid  fever 
in  the  home  camps  before  they  left  for  Cuba,  and  here  all  of  the 
conditions  were  present  for  its  rapid  spread  among  the  troops. 
Malaria,  typhoid  fever,  and  dysentery  rapidly  thinned  out  the 
ranks  and  file  of  our  army,  and  when  the  troops  returned 
every  transport  was  a  veritable  hospital.    American  inter ven- 


tion  has  gained  for  Cuba  not  only  the  long-wished-for  independ- 
ence, bat  it  has  also  brought  another  and  perhaps  greater  bless- 
ing— almost  complete  eradication  of  yellow  fever  from  this  pest- 
stricken  island.  The  wonderful  results  of  modern  sanitary 
methods  are  seen  nowhere  to  better  advantage  than  in  the  city 
made  famous  by  the  war. 

Santiago  is  the  oldest  city  in  America,  founded  by  Velas- 
quez in  1514.    Its  present  population  is  40,000.  It  has  now  direct 
railway  communication  with  Havana.     Before  and  during  the 
Spanish-American    war  Santiago  was  noted  for  its  filth  and 
pestilential  air.    The  nearby  Siboney,  the  base  of  our  opera- 
tions during  the  war,  was  shunned  even  by  the  coast  fishermen, 
as  it  had  gained  an    unenviable    reputation    as   a    neverfail- 
ing  focus  of  yellow  fever  infection.  The  moment  the  Americans 
took  possession  of  Santiago  a  vigorous  warfare  against  this  dis- 
ease was  initiated  and  prosecuted  without  a  let-up  until  this  pest- 
hole was  converted  into  one  of  the  healthiest  cities  on  the  island. 
Dr.  Leonard  Wood  proved  himself  not  only  a  brave  soldier 
but  also  a  sanitarian  of  the  highest  merits.    His  sanitary  meas- 
ures have  done  more  of  permanent  value  for  the  Cubans  in  the 
city  of  Santiago  and  elsewhere  than  his  bravery  in  the  gallant 
charge  on  San  Juan  Hill.    We  arrived  at  Santiago  Thursday, 
January  29.    As  we  passed  the  famous  Morro  Castle  the  Cuban 
flag,  a  single  star  in  the  center  of  a  red  triangle,  and  the  white 
and  blue  stripes,  was  displayed  side  by  side  with  the  familiar 
star-spangled  banner,  signifying  that  the  single  star  owed  its 
existence  to  and  claimed  the  protection  of  the  star-bedecked 
emblem  of  the  great  sister  republic  so  near  by.  Any  one  who  has 
not  seen  Santiago  since  1898  would  hardly  recognize  it  today. 
The   magnificent  asphalt  paved  streets,  the  clean  gutters  and 
utmost  cleanliness  everywhere  are  in  strong  contrast  with  the 
conditions  found  here  after  the  surrender  in  1898.  No  such  radical 
changes  would  have  taken  place  in  the  same  length  of  time  had 
the  Cubans  succeeded  in  gaining  their  independence  without 
outside  assistance.    Santiago  is  now  a  healthy  city,  made  so 
entirely  through  the  energetic  efforts  of  the  Americans  during 
the  few  years  of  their  occupation  and  rule  of  the  island.    Even 
now  the  odor  of  carbolic  acid  pervades  the  air  in  many  parts  of 
the  city  where  disease  had  formerly  its  stronghold.    A  moun- 
tain stream  supplies  the  city  with  an  abundance  of  pure  water. 
Business  has  improved,  new  industries  are  being  established, 
and  a  general  awakening  is  apparent  everywhere. 

Will  the  Cubans  ever  appreciate  to  the  fullest  extent  what 
has  been  done  for  them  by  a  modern  form  of  government,  the 
direct  outcome  of  American  intervention?  Will  the  object 
lessons  in  practical  sanitation  witnessed  by  them  during  the 
last  five  years  yield  the  expected  fruit  in  the  future?    The 


future  can  only  decide.    To  me  the  most  interesting  place  in 
Santiago  was  the  Civil  Hospital. 

Civil  Hospital.— This,  the  only  hospital  for  civilians,  was 
formerly  the  Spanish  Military  Hospital.  Material  improve- 
ments and  changes  have  been  made  to  fit  it  for  its  present  pur- 
pose. It  is  a  very  large,  square,  one-story  brick  building  with 
a  large  open  plaza  or  court  inside  for  a  number  of  large  wards 
and  ample  space  for  the  convalescents.  The  rooms  of  the  outer 
or  wall  part  of  the  building  are  largely  devoted  to  the  adminis- 
trative part  of  the  institution,  offices,  pharmacy,  operating  and 
dressing-rooms  and  a  number  of  small  wards.  Here  are  also 
found  those  suffering  from  mental  diseases.  These  patients  are 
brought  here  for  observation  for  a  period  of  30  days  when,  if 
found  insane,  they  are  sent  to  the  Insane  Asylum  at  Havana  for 
treatment  and  further  safekeeping.  The  medical  staff  consists 
of  four  attending  physicians  and  two  resident  internes.  An 
American  trained  nurse  is  at  the  head  of  the  training-school  for 
nurses.  The  training  of  the  native  nurses  consists  iu  lectures 
by  the  attending  physicians  and  recitations  and  demonstrations 
by  the  head  nurse.  They  are  required  to  pursue  their  training 
and  studies  for  three  years ;  at  the  end  of  this  time  they  are 
subjected  to  a  rigid  examination  and  if  found  qualified  receive 
a  certificate  to  this  effect. 

It  is  the  expectation  of  the  managers  of  the  school  that  a 
sufficient  number  of  trained  nurses  can  soon  be  supplied  to  the 
well-to-do  patients  in  the  hospital  and  private  homes.  Pro- 
vision is  made  in  the  hospital  for  private  patients  at  the  rate  of 
$1.25  a  day.  There  are  at  present  252  patients  in  the  hospital. 
During  the  last  year  it  cared  for  more  than  4,000  patients  and 
520  operations  were  performed.  The  operating-room  is  large, 
well  lighted  and  equipped  with  all  necessary  appliances  for 
modern  surgical  work.  We  were  fortunate  in  finding  Dr. 
Ramon  Neyra,  a  member  of  the  attending  staff,  on  duty.  He 
is  a  graduate  of  Bellevue  Hospital  Medical  College,  New  York, 
and  until  recently  practised  his  profession  at  Panama.  He  is  a 
progressive  man  and  takes  a  deep  interest  in  the  success  of  this 
new  institution  and  the  welfare  and  comfort  of  his  patients. 
The  scrupulous  cleanliness  throughout  the  institution  speaks 
well  for  the  industry  and  intelligence  of  the  foreign  and  native 
female  nurses.  Among  the  more  interesting  cases  shown  was  a 
case  of  chronic  tetanus.  The  patient  was  treated  by  antitetanic 
serum  and  chloral  hydrate  and  was  on  the  way  to  recovery 
after  an  illness  of  more  than  six  weeks.  Second,  a  case  of 
gunshot  wound  of  the  neck.  In  this  case  a  30-caliber  bullet 
entered  the  mouth,  penetrated  the  tongue  near  the  tip  and  was 
extracted  the  day  before  our  visit  through  an  incision  in  the 
posterior  part  of  the  neck.   Also  a  number  of  radical  operations 


for  hernia  and  several  cases  of  laparotomy  for  different  indi- 
cations were  shown. 

Havana.  — The  tourist  who  visited  Havana  before  the 
Spanish-American  war  will  be  astonished  and  pleased 
at  the  remarkable  changes  which  have  taken  place  since. 
I  saw  Havana  two  years  before  the  American  army  lauded 
on  Cuban  soil.  The  Spanish  flag  then  waved  over  Morro 
Castle  and  Spanish  troops  paraded  the  streets  of  the  city. 
A  guerrilla  warfare  was  then  in  progress  with  the  discontented, 
oppressed  Cubans.  Business  was  dull,  and  the  merchants 
looked  with  apprehension  into  the  uncertain  dark  future.  The 
harbor  reeked  with  filth,  the  streets  were  dirty,  all  improve- 
ments at  a  standstill.  The  water  supply  was  contaminated,  and 
sewerage  was  either  entirely  lacking,  or  at  any  rate  very  defec- 
tive. Yellow  fever  had  a  firm  and  permanent  foothold  on  the 
soil  and  in  the  many  unsanitary  dwellings  of  the  poor.  I 
visited  the  Spanish  Military  Hospital  at  that  time.  It  was  an 
immense  ancient  pile  of  stone  and  cement,  without  any  indi- 
cations of  w^hat  modern  surgery  had  accomplished.  It  con- 
tained a  number  of  yellow  fever  patients,  some  of  them  in  a 
dying  condition.  In  the  surgical  wards  I  found  a  large  num- 
ber of  wounded.  All  wounds  were  suppurating.  Erysipelas, 
phlegmonous  inflammation,  osteomyelitis  and  necrosis  were 
the  rule  in  gunshot  wounds  of  the  bones.  The  surgeons  who 
made  their  rounds  used  the  same  probe  in  examining  the 
wounds,  as  they  proceeded  from  ward  to  ward,  without  even 
taking  the  pains  of  subjecting  it  to  ordinary  cleansing,  to  say 
nothing  of  disinfection.  Hands  were  washed  when  the  work 
was  done.  What  I  saw  at  that  time  was  the  surgery  of  half  a 
century  ago.  It  is  remarkable  what  changes  have  taken  place 
since  the  American  troops  took  possession  of  the  city.  The 
Spanish  colors  have  disappeared  from  the  flagstaff  of  Morro 
Castle,  and  its  place  has  been  taken  by  the  flag  of  the  new- 
born republic  of  Cuba.  Back  of  Morro  Castle,  on  an  eminence 
rising  from  the  sea,  the  Stars  and  Stripes  wave  over  the  camp 
of  several  companies  of  our  soldiers  who  still  remain  to  pro- 
tect the  interests  of  our  country. 

•  The  wreck  of  the  "  Maine"  sleeps  in  the  clear  water  of  the 
harbor  as  a  .silent  reminder  of  the  immediate  cause  which 
provoked  the  final  struggle  of  the  island  for  liberty  and  inde- 
pendence, Havana  is  now  a  prosperous,  progressive  city  with 
250,000  inhabitants.  The  well  paved  streets  are  models  of  clean- 
liness, the  sewerage  and  water  supply  are  the  best  in  the  world. 
Business  is  thriving  and  a  general  air  of  prosperity  is  notice- 
able on  every  side.  Old  buildings  are  being  renovated  and 
naany  new  ones  are  in  process  of  construction.  Yellow  fever 
no  longer  hangs  over  the  city  like  a  threatening  cloud.    A 


vigorous  battle  against  its  bacterial  cause,  inaugurated  and 
prosecuted  with  unremitting  energy  by  American  sanita- 
rians, has  wiped  out  of  existence  this  scourge  from  this  part 
of  the  island.  The  Spanish  Arsenal  has  been  converted  into  a 
modern  university,  and  the  Spanish  Military  Hospital  is  now 
the  General  Hospital  for  the  poor  of  the  city,  greatly  improved 
and  well  managed.  The  "  General  Wood  Laboratory "  is  a 
scientific  institution  of  which  a  much  older  country  might  well 
be  proud.  Old  Havana  has  discarded  its  ancient  dress  and 
has  taken  a  place  in  an  entirely  new  attire,  well  to  the  front 
in  the  ranks  of  the  healthiest,  most  interesting  and  progressive 
cities  of  the  present  day.  The  inarvelous  changes  which  this 
city  has  undergone  have  been  as  radical  as  they  have  been 
speedy.  Five  years  is  a  short  time  for  a  stagnant  old  city  to  pass 
through  such  a  complete  renaissance.  All  of  this  has  been 
accotnplished  largely  by  American  assistance,  American  intel- 
ligence, and  by  American  energy  and  enterprise.  It  remains 
now  for  the  Cubans  to  take  up  the  work  of  maintaining  what 
they  have  gained,  and  now  and  in  the  future  to  imitate  the 
example  of  their  well-meaning  strong  ally,  to  whom  their  grati- 
tude should  be  sincere  and  lasting. 

Centra  A.sfiiriano  Hospital.— To  the  medical  visitor  the  hos- 
pital facilities  of  Havana  offer  the  greatest  interest.  The  city  is 
well  provided  with  hospitals,  private  and  public,  nine  in  all. 
In  all  of  the  places  we  had  visited  before  during  the  cruise 
among  the  West  Indies,  none  of  the  hospitals  had  desirable 
accommodations  for  private  patients.  In  a  few,  pay  patients 
were  received,  but  none  of  them  had  private  rooms.  In 
Havana  there  are  two  public  hospitals  devoted  to  the  care  of 
the  sick  poor,  the  rest  are  private  hospitals  established  and 
maintained  by  mutual  aid  societies.  Of  these  the  Centro  Asturi- 
ano  is  decidedly  the  largest  and  the  best.  After  visiting  the 
Santiago  Public  Hospital,  a  most  excellent  institution,  I  was  pre- 
pared to  find  a  still  better  one  in  Havana.  A  visit  to  the  Centro 
Asturiano,  however,  was  a  complete  surprise — a  revelation.  I 
found  here  a  model  hospital  eqiiipped  with  all  known  modern 
improvements,  a  hospital  which  has  no  equal  anywhere,  except- 
ing perhaps  the  Hamidie  at  Constantinople.  We  have  many 
splendid  hospitals  in  our  country,  public  and  private,  but  not 
one  of  them  can  compare  with  this  magnificent  structure  in  the 
infant  Cuban  republic.  It  is  the  property  of  the  Central 
Asturian  Society,  an  organization  to  which  Cubans  and 
Spaniards  are  eligible  alike,  all  of  the  members  of  which  pay 
|1.50  a  month,  for  which  consideration  they  are  entitled  to  free 
medical  treatment  at  the  dispensary  and  hospital.  The  branch 
of  the  society  which  built  and  supports  this  hospital  numbers 
14,000  members,  and  has  therefore  an  annual  income  of  |252,000. 


The  present  capacity  of  the  hospital  is  250  beds,  and  the 
number  of  patients  178.  It  is  next  to  impossible  to  give 
a  description  of  this  hospital  that  will  do  it  justice.  The 
uninitiated  visitor  finds  something  new  and  novel  with  every 
step  he  takes.  In  the  first  place  the  site  of  the  hospital  is  a  well 
chosen  one.  It  is  situated  on  a  tract  of  land  which  comprises 
no  less  than  100  acres,  near  the  southern  limits  of  the  city, 


^, 


Fig.  I.— Administrative  building.  Centre  Asturiano  Hospital.    Fig.  II. 
—Operating  pavilion,  Centre  Asturiano  Hospital,  front  view. 


made  readily  accessible  by  an  electric  tramway.  The  hospital 
occupies  the  highest  point  of  the  hill,  but  is  hidden  out  of 
sight  by  tall  trees  which  line  the  avenue  leading  from  the 
entrance  to  the  buildings.  As  one  enters  the  arched,  artistic 
gate,  he  finds  himself  in  a  beautiful  park  with  indigenous  trees, 
shrubs,  and  a  great  variety  of  tropical  flowers.  Near  the  center 
of  the  park  is  an  artificial  lake,  spanned  at  one  end  by  an 


9 

arched  bridge  of  exquisite  architectural  design.  Eighteen 
pavilions  make  the  present  group  of  buildings,  arranged 
around  a  large  park-like  court.  All  of  the  buildings  are  one- 
story  structures  with  solid  stone  walls  of  roughly  hewn  stone 
coated  on  both  sides  with  cement,  painted  on  the  outside  a  faint 
blue  and  salmon  color,  and  all  of  the  door  frames  azure  blue, 
which  adds  much  to  their  attractive,  pleasing  appearance.  The 
inside  walls  and  ceilings  are  frescoed,  the  details  of  which 
exhibit  the  good  taste  and  great  skill  of  the  artist.  All  of  the 
wards  have  a  broad  open  space  or  passageway  the  entire  length 
of  the  room  with  the  comfortable  cozy  little  private  rooms  with 
one  and  two  beds  on  each  side  opening  into  it.  The  inner  wall 
of  the  rooms  is  a  frame  partition  with  a  space  of  at  least  five  feet 
between  it  and  the  high  ceiling,  thus  affording  every  facility 
for  free  ventilation  of  every  room,  or  rather  compartment. 
The  wide  central  hall  or  passageway  is  furnished  with  chairs 
and  small  round  tables.  Here  the  patients  who  are  not  confined 
to  bed  take  their  meals,  from  one  to  four  at  each  table.  All  of 
the  floors  are  made  of  tiling. 

At  the  time  of  our  visit  the  principal  meal  of  the  day  was 
served.  The  table  ware  was  as  good  as  in  any  first-class  res- 
taurant. The  dinner  consisted  of  roast  beef,  stewed  Spanish 
peas,  excellent  white  bread,  vegetables,  and  a  glass  of  Spanish 
claret.  The  operating  pavilion  is  a  study  in  itself.  From  a 
central  passageway  doors  lead  into  the  sterilization,  disinfect- 
ing, instrument  and  anesthesia  rooms.  The  large  operating- 
room  is  reserved  for  aseptic  cases  exclusively  and  is  faultless 
in  its  construction.  The  collection  of  instruments,  all  of  them 
imported  from  Paris,  contains  everything  the  surgeon  will  ever 
need  in  performing  any  operation  and  much  to  spare.  The 
instrumeutarium  alone  represents  the  cash  value  of  a  small 
fortune.  The  sterilization-room  is  perfection  itself.  It  is  cer- 
tainly a  great  privilege  to  operate  under  such  perfect  condi- 
tions and  it  is  not  difficult  to  understand  why  the  results  should 
not  be  within  the  range  of  all  that  is  attainable  in  this  age  of 
successful  surgery.  One  large  pavilion  is  used  as  a  storehouse, 
another  for  the  reception  of  patients  and  sterilization  of  cloth- 
ing and  bedding.  The  kitchen  is  a  separate  building,  equipped 
with  every  possible  convenience.  The  washhouse  contains  the 
most  modern  machinery.  The  pride  of  the  institution,  how- 
ever, will  be  the  bathhouse  that  is  nearing  completion.  All 
around  the  central,  porcelain-lined  swimming  bath  are  bath- 
rooms for  special  baths,  such  as  Turkish,  Russian,  douche, 
electric  and  medicated  baths.  It  is  impossible  to  conceive  of  a 
more  perfect  bathing  establishment  than  this,  and  it  is  doubt- 
ful if  it  has  an  equal  anywhere.  A  Chicago  firm  was  the  suc- 
cessful bidder  for  the  construction  of  this  part  of  the  hospital, 
and  the  firm  needs  no  better  recommendation  than  the  work 


10 


done  here.  It  would  require  too  much  space  to  describe  in 
detail  the  many  unique  features  of  this  wonderful  institution 
for  the  sick,  it  must  be  seen  to  be  understood  and  appreciated. 
Not  a  dollar  has  been  foolishly  expended,  everything  is  simple 
and  yet  elegant  and  eminently  practical.  It  will  be  for  a  long 
time  an  object  lesson  for  all  architects  who  are  to  prepare  plans 
for  new  hospitals  in  our  as  well  as  more  distant  countries.  The 
society  employs  three  physicians  at  salaries  ranging  from  |150 
to  ^300  per  month,  and  two  resident  internes.  The  number  of 
female  patients  so  far  has  been  very  small  and  these  are  cared 
for  by  a  trained  female  nurse  ;  the  remaining  nurses  are  males, 
most  of  whom  received  their  training  in  the  Spanish  and  Cuban 
armies.  A  corps  of  well-trained  female  nurses  is  all  this  hospital 
requires  to  place  it  at  the  very  head  of  all  institutions  of  its 
kind.  The  hospital  on  the  present  large  scale  was  commenced 
six  years  ago,  and  new  buildings  are  being  added  as  the 
demands  upon  it  increase.  A  few  interesting  points  concern- 
ing the  surgical  work,  I  have  taken  from  a  report  published  in 
1901.  The  chief  operator  is  Dr.  Manuel  V.  Bango.  The  statis- 
tics embrace  all  operations  performed  from  March,  1897,  to 
July,  1901.  The  number  of  operations  was  2,066.  Of  these 
2,057  patients  recovered  and  only  9  died.  This  is  certainly  a 
record  it  would  be  impossible  to  duplicate  elsewhere.  The 
results  undoubtedly  are  unexcelled,  but  it  must  not  be  forgotten 
that  among  the  operations  we  find  furuncle  mentioned  152 
times ;  cold  abscess,  237  ;  felon,  51 ;  hemorrhoids,  39  ;  enuclea- 
tion of  inguinal  glands,  168;  hydrocele  operations  by  injection 
and  incision,  327;  fistula  in  ano,  29;  gradual  dilation  of  the 
urethra  in  stricture,  62 ;  and  many  other  minor  surgical  proce- 
dures which  should  not  be  attended  by  any  mortality.  Of  the 
120  Bassini  operations  for  hernia  1  patient  died :  of  2  lapar- 
otomies for  gunshot  wound  1  patient  died,  and  of  3  opera- 
tions for  strangulated  hernia  2  patients  died.  During  the  same 
period  of  time  the  number  of  patients  was  18,435.  Of  these 
18,073  recovered  and  362  died,  a  total  mortality  of  1.96%. 

Real  Hospital  de  San  Lazarus.— The  Royal  Hospital  of  St. 
Lazarus  is  the  asylum  for  lepers.  It  is  an  old  two-story  square 
stone  and  cement  building,  divided  in  the  middle  by  a  connect- 
ing wing  which  separates  the  open  square  or  court  into  two 
spaces  of  equal  size  and  which  separates  the  male  from  the  female 
patients.  It  has  been  the  home  for  this  unfortunate  class  of 
patients  since  the  founding  of  the  institution  50  years  ago.  Its 
inmates  are  under  the  watchful,  tender  care  of  the  Sisters  of 
Charity  St.  Vincent  de  Paul. 

At  present  seven  Sisters,  with  a  long  and  trying  experience, 
remain  faithful  at  their  post.  Their  willing  hands  and  cheerful 
faces  have  done  much  in  modifying  the  gloom  that  necessarily 


11 


hangs  over  the  inmates  of  such  a  home  where  there  is  so  little 
hope  of  recovery  or  escape.  The  present  number  of  lepers  is 
117.  A  second  asylum  for  lepers,  with  40  inmates,  is  located  at 
Santiago.  The  laws  of  Cuba  make  segregation  compulsory.  A 
person  suspected  of  having  the  disease  is  examined  by  a  com- 
mission of  three  physicians,  and  if  declared  a  leper  is  sent  to 
one  of  the  two  asylums,  where  he  is  held  until  he  dies  or 
recovers.  The  Sister  Superior  made  the  statement  that  during 
the  last  three  years  two  or  three  patients  were  discharged  cured. 
In  these  cases  it  would  be  well  to  place  an  interrogation  mark 
behind  the  diagnosis  in  the  records  of  the  hospitals.  The 
youngest  patient  in  the  hospital  is  a  boy  of  12.  One  of  the 
inmates,  a  Cuban  by  birth,  claims  he  contracted  the  disease 
during  a  prolonged  residence  at  Key  West.  He  said  he  was 
covered  with  boils  all  over  the  body.  His  skin  is  now  clear 
and  he  presents  no  evidences  of  being  atfected  with  the  macu- 
lar form  of  the  disease.  Visitors,  relatives  and  friends  are  per- 
mitted to  enter  the  hospital  at  any  time  of  the  day,  but  the 
patients  are  strictly  confined.  They  are  well  cared  for  and 
appear  to  be  as  contented  with  their  unhappy  lot  as  circum- 
stances will  permit.  The  building  is  situated  on  the  seashore 
drive,  where  the  patients  receive  the  benefits  of  the  cool, 
refreshing  ocean  breeze. 

Neio  Providence. — New  Providence  is  one  of  the  Bahama 
group  of  islands,  and  is  well  known  as  a  popular  winter  resort  for 
tourists  and  invalids  from  the  north.  The  number  of  inhabitants 
does  not  exceed  15,000.  The  little  island  is  flat  but  is  very  attrac- 
tive with  its  tropical  foliage,  graceful  palms,  ciba,  cedar,  silk  cot- 
ton and  tamarind  trees,  and  luxuriant  vegetation.  Nassau  is  the 
seat  of  the  English  colony  of  the  Bahamas.  The  Colonial  Hotel, 
an  American  enterprise,  is  an  immense  and  beautiful  building 
facing  the  harbor.  During  the  three  winter  months  it  is  open 
to  the  public.  For  a  midwinter  rest  it  would  be  difficult  to  find 
a  more  soothing  climate  than  Nassau  and  a  more  comfortable 
hotel  than  t]ie  Colonial.  Dr.  W.  E.  Bullard,  a  wellknown  New 
York  physician,  spends  his  winter  vacations  here  and  attends 
to  the  medical  needs  of  the  patrons  of  the  hotel.  His  genial 
disposition  and  medical  skill  have  earned  for  him  a  well 
merited  reputation  as  a  successful  physician  here  and  in  New 
York.  The  city  itself  is  quiet  and  orderly,  and  during  the 
winter  months  the  climate  is  delightful.  The  many  beautiful 
drives,  the  sea  bathing  and  yachting,  the  wonders  of  the  unique 
sea  garden,  and  the  mysterious  fascination  of  the  "  Lake  of 
Fire,"  afford  pleasing  attractions  for  recreation  and  mental 
diversion  and  rest. 

Neto  Providence  Asylum. — The  Colonial  Government  of  the 
Bahamas  has  to  deal  with  a  somewhat  mixed  method  of  taking 


12 


care  of  its  sick  and  poor.  The  New  Providence  Asylum,  Nas- 
sau, is  the  only  public  institution  for  the  dispensation  of  public 
charity.  It  is  situated  near  the  center  of  the  little  city  on 
ample  grounds,  which  have  been  improved  only  in  part.  It 
hardly  deserves  the  distinction  of  a  hospital.  It  was  founded 
in  1832  and  was  at  first  intended  as  a  home  for  the  poor.  In  the 
course  of  time  provision  had  to  be  made  for  the  insane  and 
lepers,  so  that  by  a  gradual  process  of  evolution  it  has  become  a 
combination  of  poorhouse,  insane  asylum,  hospital,  and  lepro- 
sery,  retaining,  however,  its  original  purpose  as  the  preponderat- 
ing feature.  This  complex  and  certainly  very  unique  institution 
is  in  charge  of  Dr.  L.  D.  Parsons,  a  charming  personality.  Dr. 
Parsons  is  a  graduate  of  Edinburgh  and  has  been  at  the  head 
of  the  management  of  the  asylum  for  a  year.  He  has  already 
made  many  important  changes,  and  has  in  contemplation  many 
more  calculated  to  bring  the  asylum  up  to  the  standard  of 
present  requirements.  The  possibilities  in  this  direction  are 
great  and  we  wish  our  colleague  the  very  best  success  in  his 
humane  endeavors.  The  buildings  are  all  two-story  stone  and 
cement  pavilions.  The  one  that  serves  as  a  hospital  has  40 
beds.  A  trained  English  nurse  with  three  colored  helpers  is  in 
charge  of  all  of  the  inmates  of  the  asylum.  The  young  colored 
women  do  not  take  kindly  to  nursing,  as  they  do  not  look  upon 
the  occupation  of  a  nurse  as  a  profession.  The  greatest  diffi- 
culty is  encountered  in  securing  the  material,  as  the  women 
prefer  housework  to  hospital  work.  As  soon  as  a  probationer  has 
been  instructed  in  the  performance  of  her  simplest  duties  she 
is  apt  to  leave  as  soon  as  a  prospect  of  a  more  congenial  employ- 
ment presents  itself.  The  nursing  in  all  of  the  West  India  hos- 
pitals is  very  unsatisfactory,  and  will  remain  so  until  the  col- 
ored women  can  be  made  to  understand  and  realize  the  dignity 
and  high  standing  of  the  profession  of  nursing.  The  last  Eng- 
lish nurse  here  held  out  for  three  years,  when  her  health  broke 
down  from  overwork,  and  the  same  fate  awaits  the  one  who 
has  taken  her  position. 

The  poorhouse  proper  is  the  best  building  on  the  grounds, 
and  Dr.  Parsons  has  taken  the  necessary  steps  to  convert  it 
into  a  hospital  and  remove  the  inmates  to  the  present  hospital 
building,  a  most  desirable  change.  The  insane  asylum  in  the 
same  enclosure  occupies  the  top  of  the  hill,  and  has  at  present 
40  inmates.  A  number  of  the  male  patients  were  engaged  in 
chopping  wood  under  the  supervision  of  a  guard.  The  lepers, 
14  in  number,  live  in  a  separate  building,  but  are  allowed  to 
mingle  freely  with  the  other  inmates  of  the  asylum,  and  are  per- 
mitted to  leave  and  enter  the  asylum  during  the  daytime  when 
they  choose  to  do  so.  There  is  no  compulsory  segregation  in 
the  colony  of  the  Bahamas. 


13 

There  are  few  abdoniinal  sections  performed,  as  the  colored 
women  suffering  from  myofibroma  and  ovarian  tumors  who 
occasionally  enter  the  hospital  invariably  refuse  to  be  operated 
upon.  New  Providence  appears  to  be  out  of  range  of  the  trop- 
ical diseases  we  found  so  common  in  the  more  southern  of  the 
West  India  islands.  Elephantiasis  as  an  indigenous  disease  is 
almost  unknown,  and  ankylostoma  and  abscess  of  the  liver 
very  rare.  The  most  common  disease  is  tuberculosis.  Malaria 
of  a  mild  type  and  its  complications  make  up  a  large  part  of 
the  statistics  of  the  diseases  of  the  islands.  The  water  supply  is 
cistern  and  well  water,  and  although  Nassau  has  no  sewerage 
its  soil  is  free  from  typhoid  infection. 

On  board  "  Kaiserin  Maria  Theresa,"  Harbor  of  New  York,  Feb- 
ruary 6, 1903, 


[Reprinted  from  A?nerican  Medicine,  Vol.  V,  No.  24,  pages  964-967, 
June  13, 1903.1 


ECHOES    FROM     THE     MADRID     INTERNATIONAL 
MEDICAL  CONGRESS. 

BY 

NICHOLAS  SENN,  M.D., 
of  Chicago. 

The  Madrid  International  Medical  Congress  has  passed 
into  history.  The  members  who  attended  will  relate  their 
experiences  and  observations  in  their  respective  medical 
circles  in  near  and  remote  parts  of  the  world,  and  the  profes- 
sion at  large  will  pass  final  judgment  upon  its  scientific  merits 
after  perusal  and  study  of  its  published  transactions.  Like  in  all 
similar  events  praise  will  not  be  unmingled  with  criticism. 
The  attendance  was  larger  than  was  expected.  The  register 
contained  the  names  of  6,961  members,  of  which  number  3,53Q 
were  credited  to  Spain,  and  3,431  to  foreign  countries.  The 
foreigners  were  represented  by  the  following  countries :  Ger- 
many, 776  ;  Australia,  7  ;  Argentine  Republic,  45  ;  Austria,  258  ; 
United  States  of  Colombia,  2 ;  Cuba,  13 ;  Denmark,  35  ;  Belgium, 
98;  Bosnia,  3;  Brazil,  252;  Bulgaria,  4;  Egypt,  12;  United 
States,  195;  France,  826;  England,  238;  Greece,  9;  Hayti,  1; 
Italy,  238;  Japan,  4  ;  Luxemburg,  4  ;  Mexico,  25  ;  Norway,  51 ; 
Holland,  16;  Peru,  4;  Portugal,  33 ;  Roumania,  21  ;  Russia, 
297;  San  Domingo,  2 ;  Servia,  9;  Sweden,  21;  Switzerland,  35 ; 
Turkey,  11 ;  Uruguay,  3  ;  Venezuela,  18.  The  government,  or 
as  they  were  designated  here,  official  delegates,  numbered  474. 
Many  of  the  members  who  registered  by  mail  did  not  attend. 
The  tedious  railway  travel  in  Spain  and  the  limited  hotel 
accommodations  of  Madrid  did  their  share  in  limiting  the 
attendance;  the  many  places  of  great  historic  events  and 
the  boundless  treasures  of  art  in  which  the  country  abounds 
attracted  others  who  were  not  prompted  by  a  sense  of  hunger  or 
thirst  for  additional  medical  knowledge.  The  figures  quoted 
above  indicate  plainly  that  the  Congress  was  overwhelmingly 
Latin  in  its  make-up.  The  euphonious  Latin  languages — 
Spanish,  Portuguese,  and  Italian— were  most  in  use  in  conver- 
sation, reading  of  papers  and  discussions.  The  French  occupied 
the  second  place  in  the  scale  of  frequency.  The  average 
Spaniard  has  but  little  desire  to  acquire  foreign  languages. 
Nearly  all  of  the  educated  classes  speak  French,  very  few  Eng- 
lish or  German.    Among  the  medical  men  German  is  a  rare 


accomplishment  and  only  a  limited  nvimber  of  naval  surgeons 
have  acquired  a  speaking  knowledge  of  English.  In  the  section 
meetings  English  was  seldom  heard  and  German  even  less 
frequently.  A  fair  estimate  of  the  number  of  delegates  in 
actual  attendance  would  be  about  5,000.  The  delegates  were 
divided  into  three  classes :  (1)  Official  or  government  delegates, 
who  received  a  gold  badge  with  a  ribbon  of  the  national  colors ; 
(2)  delegates  from  medical  societies  or  scientific  institutions, 
who  wore  a  silver  badge  with  ribbon;  and  (3)  members  of  the 
Congress  by  subscription,  who  were  labeled  with  a  plain  gold 
badge.  These  badges  played  an  important  role  in  the  selection 
for  a  number  of  the  most  important  social  features,  the  official 
delegates  being  shown  a  decided  preference. 

Opening  Exercises. — Long  before  the  time  set  for  the  open- 
ing of  the  Congress,  at  3  p.m.  Thursday,  April  23,  the  Royal 
Opera  House  was  packed  with  a  brilliant  audience.  On  the 
floor  every  inch  of  available  standing  room  was  occupied  by  a 
seething  mass  of  humanity.  The  boxes  were  filled  by  distin- 
guished government  officials,  prominent  citizens,  military  and 
naval  officers  in  full-dress  uniforms,  and  invited  guests.  When 
the  young  King  entered  the  royal  box  accompanied  by  his 
mother.  Infanta  Maria  Theresa,  and  Infanta  Isabel,  the 
immense  audience  rose  as  a  body  and  the  band  playei  the 
royal  march.  The  royal  party  was  not  cheered  so  vociferously 
as  is  the  case  when  one  of  our  Presidents  makes  his  appear- 
ance on  a  similar  occasion,  but  the  greeting  was  a  well-meant 
one,  and  was  participated  in  heartily  by  the  foreign  delegates 
from  all  parts  of  the  world.  The  youthful  potentate  and  his 
august  mother  made  a  very  favorable  impression  upon  every 
one  present.  The  King  listened  attentively  for  two  hours  to  the 
addresses  of  welcome  and  the  numerous  long  and  short 
responses.  An  incident  occurred  here  which  excited  some 
newspaper  and  public  comment.  When  our  country  was 
called  upon  to  respond  a  profound  and  at  the  time  a  painful 
silence  was  the  only  reply.  The  call  was  repeated  with  the 
same  result.  What  was  interpreted  by  some  as  an  intentional 
slight  to  Spain  on  part  of  our  delegation  was  simply  due  to  a 
lack  of  organization  of  our  delegates  at  this  as  well  as  subse- 
quent occasions,  for  which  no  individual  delegate  was  to  blame, 
but  something  which  should  be  studiously  avoided  in  the 
future.  As  it  was  no  one  felt  authorized  to  respond,  when  our 
country  was  called  upon,  through  its  scattered  delegates.  The 
matter  was  subsequently  explained  to  the  proper  authorities, 
and  on  leaving  Madrid  I  was  informed  by  a  Spanish  naval 
officer  of  high  rank  that  this  incident  created  rather  a  favorable 
impression  than  otherwise  among  his  countrymen.  The  King 
wore  the  uniform  of  a  field  marshal.    He  did  not  speak.     I  was 


informed  that  "  in  public  the  King  never  speaks."  The  Royal 
Theater  is  a  large  and  magnificent  structure,  but  its  interior 
proved  entirely  inadequate  to  afford  even  standing  room  for 
the  immense  throng  desirous  of  witnessing  the  opening  cere- 
monies, the  most  attractive  feature  of  every  International  Med- 
ical Congress. 

General  Sessions.— The\9.^i  session  of  the  Congress  was  held 
in  the  large  amphitheater  of  the  Central  University.  At  this 
meeting  it  was  announced  that  the  Moscow  and  Paris  prizes  for 
the  best  scientific  work  had  been  awarded  to  Grassi,  of  Rome, 
and  Metschnikoff,  of  Paris,  and  that  Lisbon,  Portugal,  had 
been  selected  for  the  next  place  of  meeting. 

By  what  motives  and  manner  of  reasoning  the  committee 
on  nominations  decided  upon  Lisbon  as  the  next  place  for  the 


Fig.  1.— Royal  Palace. 

Congress  is  difficult  to  comprehend.  This  action  necessarily 
means  two  consecutive  Latin  congresses  and  will  inevitably  cut 
down  the  attendance  to  a  minimum.  Lisbon  is  a  much  smaller 
city  than  Madrid,  its  hotel  accommodations  more  limited,  and 
it  is  also  less  accessible;  all  serious  objections  against  this 
selection,  to  say  nothing  of  the  fact  that  the  Latin  languages 
will  again  rule  the  deliberations  of  the  Congress.  Portugal  is 
an  interesting  country  to  visit.  Lisbon  is  a  charming  little 
city,  but  the  next  Congress  should  have  met  in  a  more  central 
place  and  in  a  large  city  with  ample  hotel  accommodations  and 
in  a  country  where  the  English  and  German  languages  carry 
more  weight.  If  a  general  criticism  of  the  Congress  just 
ended  is  permissible  it  is  the  fact  that  the  hotel  facilities  of 


Madrid  were  inadequate  to  the  requirements  of  so  large  an 
attendance,  and  this  difficulty  will  be  greatly  increased  at  the 
next  place  of  meeting.  I  am  confident  the  United  States  will 
send  the  usual  large  contingent  of  delegates,  who  will  repre- 
sent in  a  creditable  manner  the  scientific  work  of  our  profession 
notwithstanding  the  inconveniences  they  will  meet  in  finding 
accommodations,  and  the  difficulties  they  will  have  to  encoun- 
ter in  making  themselves  understood. 

During  the  intervening  days  the  general  sessions  were  held 
in  the  aula  of  the  San  Carlos  College  of  Medicine.  Sixteen 
speakers  were  on  the  program,  among  them  Dr.  Howard  A. 
Kelly.  The  title  of  the  address  of  this  speaker  was  a  signifi- 
cant one:  "  The  Passing  of  a  Specialty."  The  time  of  the  gen- 
eral sessions,  called  here  conferences,  interfered  seriously  with 
the  work  of  the  sections,  and  it  was  probably  for  this  reason 
that  the  attendance  was  small.  Among  the  more  distinguished 
speakers  may  be  mentioned  Waldeyer,  of  Germany  ;  Politzer, 
of  Austria;  Arthur  Thomson,  of  Oxford;  Brouardel  and 
Robin,  of  Paris  ;  Maragliano,  of  Italy,  and  Pawloff,  of  Russia. 

Section  Work. — There  was  at  this  as  well  as  all  previous 
meetings  of  the  International  Medical  Congress  no  lack  of 
papers  for  all  of  the  sections.  The  furore  of  the  pen  of  the 
present  generation  of  medical  men  is  made  obvious  at  all  gath- 
erings from  the  smallest  county  and  city  medical  societies  up  to 
the  International  Medical  Congress.  The  average  attendant  is 
no  longer  content  to  listen  and  learn;  he  is  imbued  with  a 
sense  of  duty  that  compels  him  to  produce,  to  write,  to  teach. 
The  result  of  such  a  crowded  program  was  here  the  same  as 
elsewhere  on  similar  occasions.  The  limited  time  allotted  to 
each  paper  made  the  reader  anxious  to  go  over  as  much  ground 
as  possible,  hence  he  felt  it  his  duty  to  read  rapidly,  which  only 
too  often  meant  unintelligibly,  followed,  if  by  any,  a  short  and 
imperfect  discussion  of  the  subject  presented.  The  scientific 
work  of  such  a  large  assemblage  of  medical  men  must  of  neces- 
sity be  done  in  the  different  sections.  The  section  program  of 
the  Madrid  Congress  was  an  unusually  prolific  one,  comprising 
the  titles  of  nearly  2,000  papers  on  every  possible  subject  per- 
taining to  medicine  and  surgery  and  allied  sciences.  These 
papers  were  distributed  among  16  sections  and  several  sub- 
sections. Many  of  the  authors  of  papers  announced  on  the  pro- 
gram were  conspicuous  for  their  absence,  an  evil  by  no  means 
limited  to  the  International  Congress  and  one  which  should 
receive  the  earnest  attention  of  the  committee  on  program.  It 
is  not  at  all  unusual  for  authors  to  send  in  the  titles  of  papers 
they  never  intended  to  prepare,  much  less  to  present  them  in 
person.  Such  deception  deserves  censure  and  should  be  made 
impossible  by    more    stringent    regulations.      Another    quite 


noticeable  irregularity  is  the  presentation  of  papers  after  they 
have  done  service  at  some  previous  medical  society  meeting  and 
after  they  have  found  space  in  some  medical  journal  months  and 
years  before  their  resurrection  on  such  an  important  occasion. 
In  looking  over  the  general  program  I  had  no  difficulty  in 
detecting  a  number  of  very  familiar  titles.  The  friendly  spirit 
of  the  Spaniards  toward  the  Americans  became  manifest  when 
it  came  to  the  distribution  of  section  honors.  The  following 
delegates  were  made  honorary  presidents  of  sections:  Dr. 
Howard  A.  Kelly,  Gynecology;  Professor  Stuart,  Chicago, 
Physiology ;  Dr.  Reginald  Sayre,  Diseases  of  Children  ;  Dr.  C. 
H.  Hughes,  Neurology  ;  Dr.  R.  H.  Reed,  General  Surgery  ;  Dr. 
Harlan,  Dentistry;  Surgeon-General  O'Reilly  and  Dr.  N.  Senn, 
Military  Surgery.    All  of  the  sections  held  their  meetings  in  the 


Fig.  2.— National  Museum  and  Gallei-y  of  Modern  Art. 


National  Art  Gallery  and  Museum,  a  spacious  and  imposing 
structure,  a  lasting  monument  to  Spain's  perpetual  interest  in 
the  preservation  and  promulgation  of  art.  This  centralization 
of  section  work  had  many  advantages,  but  was  not  without 
objection.  This  magnificent  building  is  centrally  located  and 
easily  accessible,  but  the  proximity  of  the  sections  and  the 
many  priceless  art  treasures  afforded  too  many  diversions  from 
continuous  hard  section  work.  The  ^^  congi^essiste"  could  not 
resist  the  temptation  in  passing  through  the  building  to  note 
what  was  going  on  in  the  different  sections  and  to  study  and 
admire  the  wonderful  paintings,  illustrating  modern  Spanish 
art.  Then,  too,  the  picture  galleries  were  open  to  the  public,  a 
circumstance  which  contributed  its  share  in  aggravating  the 
confusion.    The  section  meetings  were  held  from  9  o'clock  a.m. 


6 


until  noon  and  often  the  time  was  extended  for  another  hour  or 
two.  As  a  rule,  the  man  who  spoke  loudest  and  was  most  lib- 
eral in  making  gesticulations  enjoyed  the  largest  attendance. 
As  indicated  by  the  titles  of  the  papers  presented,  most  of  the 
modern  subjects  which  are  at  this  time  agitating  the  progressive 
professional  minds  were  ably  presented  and  thoroughly  dis- 
cussed. Some  of  the  most  valuable  papers  were  presented  by 
Spanish  authors.  The  Spaniards  are  fluent  speakers  and 
delight  in  debate.  Spain  is  keeping  pace  with  her  European 
neighbors  in  the  advancement  of  the  science  and  art  of  medicine. 
The  forthcoming  transactions  of  the  Congress  will  bear  ample 
testimony  to  the  correctness  and  force  of  this  statement.  We 
must  come  in  closer  touch  with  Spanish  medical  literature  if  we 
wish  to  keep  apace  with  the  newest  and  some  of  the  best  work 
that  is  being  done  in  unraveling  the  mysteries  of  disease  and 
in  search  of  new  and  more  effective  therapeutic  resources. 

Spain  can  no  longer  afford  to  hide  what  she  has  done  toward 
the  advancement  of  modern  medicine  within  her  own  bound- 
aries ;  her  excellent  work  in  this  direction  must  become  com- 
mon property  wherever  scientific  medicine  is  taught  and 
practised.  One  of  the  striking  defects  of  the  section  w^ork  in 
most,  if  not  all,  of  the  sections  was  the  limited  number  of 
demonstrations— the  teaching  by  the  kindergarten  method. 
This  lack  of  practical  demonstration  was  keenly  felt  by  those 
who  were  not  familiar  with  the  languages  in  most  common 
use.  The  too  numerous  and  often  quite  lengthy  papers 
undoubtedly  constituted  a  bar  to  more  satisfactory  and  extended 
demonstrative  teaching  and  if  so  this  obstruction  should  be 
eliminated  at  the  next  meeting  of  the  Congress.  What  the 
seeker  for  knowledge  on  an  occasion  like  this  desires  most  and 
looks  for  are  ocular  demonstrations  illustrative  of  the  ideas  the 
speaker  desires  to  convey  to  his  audience.  The  section  meet- 
ings were  not  so  well  attended  as  one  would  expect  after  look- 
ing over  the  subjects  scheduled  in  the  general  program.  Too 
many  of  the  delegates  had  come  with  the  intention  of  doing 
sightseeing  instead  of  attending  to  the  legitimate  duties  of  the 
mission  on  which  they  had  been  sent.  This  kind  of  dereliction 
of  a  voluntarily  assumed  duty  is  only  too  common,  and  merits, 
to  say  the  least,  a  sharp  criticism.  The  confusion  of  languages 
that  prevailed  throughout  the  entire  Congress  found  its  way 
into  the  general  program.  I  will  give  only  a  few  instances  of 
title  mutilation  as  it  appeared  in  the  general  program  for  the 
authors  who  presented  papers  in  English  and  German. 

My  friend,  Dr.  C.  H.  Hughes,  of  St.  Louis,  was  announced  to 
read  a  paper  in  the  Neurological  Section  on  "  Eew  Vievos  of  the 
Virile  Reffiese."  I  wonder  what  Lindsay  Steven,  of  Glasgow, 
thought  when  he  saw  printed  under  his  name  "A  Case  of  Ocute 


Lympatic  Leukalmia  urt  Minde  vous  Lympatic  Medules  in 
the  Skin."  Dr.  R.  H.  Harvey  Reed,  of  de  Rock  Springo  Hugo, 
was  expected  to  discuss  "  Metral  d'implantation  duto  the 
Rectum."  I  was  registered  in  the  Military  Section,  and  drew  a 
long  breath  when  called  upon  to  present  my  paper  on  "  The 
First  Dirping  en  the  Battlefired." 

The  German  language  fared  no  better  than  the  English  in 
the  program. 

lam  sure  the  patriotic  feelings  of  Korbitz,  of  Berlin,  received 
a  shock  when  he  saw  his  name  coupled  with  the  title  of  his 
paper  on  "  Das  Schmelzen  des  leichtflussigen  Forzellans  una 
cin  hener  electrisher  ofen."  I  do  not  know  the  fate  of  the 
paper  by  Grunmach,  of  Berlin,  in  the  Section  of  Internal  Medi- 
cine, but  the    title  as    printed  was  certainly  a  strange   one — 


Fig.  3.— Dr.  Calleja,  President  of  the 
Congress. 


Fig.  4.— Dr.  Care,  Secretary  or 
the  Congress. 


"  Uibu  dis  Fortschritte  in  des  Diagnostik  dirrili  dis  X  Strah- 
len." 

It  would  certainly  not  be  in  good  taste  to  criticise  too 
severely  the  orthography  of  the  English  and  German  language 
in  a  product  of  the  Spanish  press,  and  I  have  quoted  these 
illustrations  only  as  a  hint  to  the  committee  on  program  for 
the  next  meeting  of  the  Congress,  to  which  I  desire  to  add  the 
well-meant  suggestion  to  consult  some  one  who  has  a  fair 
knowledge  of  the  two  languages,  which  are  too  widespread  and 
important  to  be  ignored,  before  they  deliver  the  program  to  the 
printer,  and  then  engage  the  services  of  a  competent  proof- 
reader. 

Exhibits.— One  of  the  great  attractions  at  the  meetings  of  the 
American  Medical  Association  is  the   exhibition  hall.     It  is 


8 


here  where  the  country  and  village  practitioners  replenish 
their  stock  of  proprietary  medicines  without  depleting  their 
hank  accounts  and  collect  current  medical  literature  for  their 
libraries  without  diminishing  the  contents  of  their  pocket- 
hooks.  It  is  here  where  he  can  quench  his  thirst  with  spark- 
ling waters  of  all  kinds  and  satisfy  his  sense  of  hunger  with 
predigested  bread,  milk  and  meat  without  augmenting  the  size 
of  his  boarding-house  bill.  If  he  is  so  inclined  he  can  satisfy 
his  desire  for  alcoholic  stimulants  without  invading  the  pre- 
cincts of  saloons  on  his  way  to  and  from  the  meetings,  and  all 
that  is  asked  by  the  exhibitors  for  his  Indulgences  is  the  good- 
will of  the  patrons  after  their  return  to  their  respective  fields 
of  activity.  It  is  here  where  he  can  learn  the  names  and  uses  of 
new  instruments,  apparatuses  and  splints  minutely  described 
and  illustrated  in  catalogs  which  are  distributed  with  a  liber- 
ality bordering  on  actual  extravagance.  If  any  of  the  delegates 
came  to  Madrid  with  any  such  expectations  and  intentions 
they  were  certainly  disappointed.  The  Madrid  merchants  and 
manufacturers  either  failed  to  grasp  the  opportunity  or  per- 
sisted in  conducting  their  business  in  the  usual  everyday 
routine  manner  notwithstanding  the  streets  of  the  city  were 
thronged  with  5,000  strange  doctors  from  all  parts  of  the  world. 
The  only  exhibits  and  efforts  at  advertisement  that  I  saw  were 
by  a  Paris  firm  which  dispensed  Vichy  water  and  distributed 
literature  pertaining  to  its  health-preserving  and  health-restor- 
ing qualities  with  laudable  liberality,  and  a  small  stand  where 
a  sorrowful  looking  individual  distributed  circulars  of  a  de 
luxe  edition  of  Don  Quixote.  No  books,  no  instruments,  no 
proprietary  medicines  in  sight.  In  speaking  of  the  section 
work  I  emphasized  the  fact  that  demonstration  teaching  was 
not  done  to  the  extent  it  deserves.  I  must  refer  here  to  an 
exhibit  in  the  surgical  section  of  plaster  models  by  Doctors 
Bockenheimer  and  Frohse,  of  Berlin,  which  represented  the 
dififerent  steps  of  Bassini's  operation  for  inguinal  hernia  as 
performed  in  Professor  von  Bergmann's  clinic.  A  study  of 
these  models  imparted  a  full  and  detailed  knowledge  of  the 
technic  of  the  operation  and  demonstrated  clearly  the  value  of 
such  object  lessons  in  the  teaching  of  operative  surgery.  Let 
me  express  the  hope  that  this  kind  of  section  work  will  attain 
greater  popularity  at  future  meetings  of  medical  societies,  large 
and  small,  and  more  especially  of  the  International  Medical 
Congress. 

Social  Entertainments.— Spanish  hospitality  has  become 
almost  proverbial  throughout  the  entire  world.  This  national 
virtue  is  characteristic  of  all  classes  of  society— high  and  low, 
rich  and  poor,  educated  and  ignorant.  The  hospitality  practised 
is  of  a  charming  kind,  it  is  not  a  hospitality  of  the  head  but  of 


the  heart.  The  Spaniard  makes  you  feel  that  the  hoase  you 
visit  is  your  own,  that  the  things  you  enjoy  are  furnished  by 
you,  in  fact  that  you  are  the  host  and  he  the  guest.  The  Spaniard 
is  an  ideal  entertainer,  a  polished  gentleman,  refined  in  man- 
ners, whose  pleasure  it  is  to  serve  his  friends.  The  spirit  of 
the  knighthood  days  lives  in  spite  of  time  and  great  national 
and  family  reverses.  It  makes  itself  felt  on  the  streets,  in  the 
mansions  of  the  rich  and  the  hovels  of  the  poor,  in  places  of 
public  amusement,  the  market,  shops,  and  especially  in  educa- 
tional and  charitable  institutions.  The  members  of  the  Con- 
gress regardless  of  nationality  were  made  to  feel  that  they 
were  the  guests  of  the  nation.  The  royal  family  made  its 
appearance  on  three  different  occasions  for  the  benefit  of  the 


Fig.  5. 


-Grand  Amphitheater  of  the  Faculty  of  Medicine  of  San  Carlos 
College. 


visitors.  FeM^  if  any,  crowned  heads  would  condescend  to 
receive  in  their  own  palace  several  thousand  people  in  one  after- 
noon as  was  done  by  King  Alfonso.  The  reception  at  the  palace 
at  three  o'clock  in  the  afternoon  on  the  second  day  was  a  bril- 
liant affair.  The  military  men  appeared  in  gala  uniform,  the 
ambassadors  in  court  and  citizens  in  full  dress.  At  the  entrance 
to  the  palace  the  visitors  had  to  show  the  card  of  invitation. 
The  delegates  were  grouped  in  different  rooms  according  to 
nationality.  The  Americans  were  assigned  to  the  dining-room, 
where  they  were  met  by  Minister  Hardy,  who  introduced  the 
King  to  a  number  of  delegates  who  occupied  the  front  row,  at 
the  head  of  which  stood  Surgeon-General  O'Reilly.  The  King 
was  followed  by  his  mother  and  Infanta  Maria  Theresa,  both  of 
them  dressed    in    black,   while  the  King    wore    a    handsome 


10 


uniform.  He  as  well  as  his  mother  speaks  English  and  German 
fluently,  and  conversed  in  these  languages  with  the  members 
of  the  American  delegation.  We  were  all  deeply  impressed 
with  the  modest  and  genial  manners  of  the  young  ruler  of  the 
old  nation  that  has  played  such  an  important  role  in  the  drama 
of  the  Old  World  and  made  it  possible  for  Columbus  to  find  the 
new  one.  We  Americans  must  never  forget  what  Spain  has 
done  for  us,  we  must  ever  keep  in  mind  the  jewels  of  Isabella, 
the  Catholic.  After  the  reception  we  were  invited  to  visit  dif- 
ferent apartments  and  look  at  the  wonderful  collection  of  tap- 
estry. In  the  afternoon  at  4  o'clock,  Wednesday,  April  29, 
all  of  the  delegates  and  ladies  in  attendance  were  given  a  gar- 
de"n  party  by  the  royal  family.  The  spacious  garden  behind 
the  palace  was  at  its  best.  The  soft  green  of  the  well-kept 
lawns,  the  new  headdress  of  the  giants  of  the  forest,  the  flowers 
in  all  colors,  the  many  fountains  in  action  and  the  throng  of  at 
least  5,000  people  in  their  best  attire,  made  a  picture  that  time 
will  never  efface  from  the  memories  of  those  who  were  privi- 
leged to  witness  it.  Six  bands  stationed  in  different  parts  of  the 
park-like  garden  played  alternately  while  the  people  strolled 
about  leisurely  in  the  full  enjoyment  of  a  lovely  spring  day, 
made  memorable  by  the  environments  and  the  hospitality  of 
the  King  that  prompted  the  occasion.  The  King  entered  the 
garden  in  a  carriage  accompanied  by  his  mother  and  the  two 
infantas.  After  leaving  the  carriage  the  royal  party  made  its 
w^ay  through  the  dense  crowd,  addressing  a  few  words  to  those 
standing  near  by  as  they  passed  along  the  principal  avenues  of 
the  garden. 

A  splendid  buffet  lunch,  including  champagne,  was  served  at 
a  long  table,  around  which  several  hundred  people  could  be 
seated  and  help  themselves  at  the  same  time.  This  garden 
party  was  one  of  the  most  pleasing  features  of  the  Congress  and 
I  am  sure  that  every  one  who  was  present  will  remember  with 
gratitude  the  royal  host  who,  by  his  dignified  manner  and 
charming  hospitality,  added  so  much  to  the  success  and  pleas- 
ures of  the  Congress.  Of  the  section  entertainments  I  can  only 
speak  of  the  military  section.  The  afternoon  was  devoted  to  the 
visiting  of  government  institutions,  notably  the  Military 
Hospital  and  the  Laboratory  of  the  Army  and  Navy.  These 
visits  always  ended  with  a  most  excellent  lunch,  including  the 
native  wines  and  champagne.  The  section  dinner  was  given 
in  one  of  the  dining-rooms  of  the  Ingleterra  Hotel.  The  Minis- 
ter of  War  and  a  number  of  military  and  naval  ofl&cers  of  the 
highest  rank  were  present.  The  dinner  was  one  which  it 
would  be  difficult  to  duplicate  in  America.  The  parting 
speeches  were  numerous,  in  many  languages,  and  most  of  them 
eloquent.    Contrary  to  what  we  were  made  to  believe  before  w 


11 

entered  Spain,  after  ample  experience  we  had  to  come  to  the 
conclusion  that  the  Spanish  kitchen  is  a  most  excellent  one. 
The  rooms  in  the  hotels  are  large  and  the  beds  not  only  com- 
fortable but  luxurious.  Receptions  by  the  mayor  of  the  city  and 
the  Minister  of  the  Interior  and  an  opera  party  completed  the 
list  of  entertainments. 

The  Committee  on  Entertainments  very  wisely  excluded 
from  the  program  the  national  sport— bullfighting.  It  is  needless 
to  say,  however,  that  most  of  the  delegates,  including  their 
wives,  secured  admission  tickets  in  time  and  were  in  their 
seats  at  4  o'clock  Sunday  afternoon  when  the  first  bull  made 
his  attack  on  the  poor  blindfolded  horses,  who  looked  in  vain 
for  protection  from  their  stupid  riders.  The  bull  in  turn  was 
teased,  worried  and  tired  out  when  the  gaudily  dressed  bull- 
fighter (butcher)  entered  the  ring  to  put  an  end  to  the  misery 
of  the  half  dead  brute.  This  brutal  sport  was  repeated  six 
times  before  the  program  was  finished.  The  Madrid  bullfight 
is  a  tame  affair  compared  with  that  of  the  City  of  Mexico,  and 
it  is  safe  to  say  that  no  foreign  "  congressiste"  will  ever  care  to 
witness  another  one.  The  royal  family  neither  attends  nor 
encourages  this  sport.  For  years  repeated  efforts  have  been 
made  to  suppress  it  and  its  days  are  evidently  numbered.  It  is 
a  relic  of  former  days  and  so  far  as  brutality  is  concerned  it  is 
no  worse  than  the  cockfights  and  football  games  so  well  pat- 
ronized in  our  own  country. 

Reflections.— It  is  much  easier  to  criticise  mistakes  than  to 
avoid  them.  The  local  committees  of  the  Congress  did  much 
creditable,  hard  work.  The  medical  profession  of  Madrid  and 
Spain  at  large  was  anxious  to  make  the  Congress  a  great  suc- 
cess. In  many  things  the  efforts  succeeded,  in  others  they  fell 
short  of  expectations.  The  government  officials  from  the  King 
down  to  the  employes  of  the  lowest  grade  did  their  duty.  The 
railroads  and  steamship  companies  ofifered  sufficient  induce- 
ments by  reduction  of  rates  to  secure  a  large  attendance.  Look- 
ing backward,  it  is  not  difficult  to  ascertain  where  better 
arrangements  could  have  been  made.  The  system  of  registra- 
tion was  very  defective.  No  reliable  bureau  of  information. 
Only  two  persons  were  in  charge  of  the  mail ;  it  required  both 
patience  and  perseverance  to  call  for  letters.  The  "  Bureau  de 
logement "  assumed  a  difficult  task  when  it  undertook  to  secure 
desirable  accommodations  for  the  visitors.  Many  bitter  com- 
plaints were  made  by  members  who  were  assigned  to  quarters 
outside  of  the  hotels.  The  hotel  guests  had  no  reason  for  well- 
grounded  dissatisfaction.  The  general  program  did  not  give 
the  desired  information.  The  titles  of  the  papers  for  the  sec- 
tions were  thrown  together  without  any  reference  to  the  time 
when  the  papers  were  to  be  presented  in  the  respective  sections. 


12 


The  Diario  OJicial.,  under  the  editorship  of  Dr.  Enrique 
Salcedo,  contributed  something  toward  the  remedying  of  this 
defect,  but  failed  in  doing  away  entirely  with  the  existing 
confusion.  The  Suplemento  Diario  OJicial,  containing  the 
names  and  local  addresses  of  the  members,  made  its  appearance 
on  the  day  the  Congress  adjourned.  Hence  there  was  no  way  by 
which  we  could  ascertain  the  addresses  of  friends  we  w^ere 
anxious  to  meet  and  visit.  Nine  numbers  of  the  Diario 
were  issued,  the  last  number  the  day  after  the  Congress 
adjourned.  The  foregoing  are'some  of  the  shortcomings  of  the 
Arrangement  and  Program  Committees  which  should  be 
remembered,  and,  if  possible,  avoided  by  those  who  will  be 
placed  in  charge  of  the  management  of  the  next  Congress.  On 
the  whole,  however,  we  fared  much  better  than  we  had  reason 
to  anticipate.  The  merits  of  the  Congress  overshadow  the 
demerits  ;  the  pleasures,  the  disappointments.  We  can  say  with 
the  editor  of  the  Diario  Oficial  (NumeroS):  "Le  lien  n'est 
pas  opportun  pour  parler  des  fruits  du  Congres,  ils  sont  con- 
signes  dans  les  Actes  qui  seront  comme  un  livre  d'or,  dans  le 
vaste  champ  des  sciences  medicales,  mais  nous  pouvons  bien 
dire  que  le  XIY*'"^  Congres  de  Medecine,  continue  la  glorieuse 
tradition  des  anterieurs  et  qu'  il  est  I'honneur  de  notre 
Facuite." 

Two  evils  threaten  the  future  successes  of  the  International 
Medical  Congress.  They  are :  1.  Too  great  laxity  in  the  admis- 
sion to  membership.  2.  Too  large  attendance.  The  elimination 
of  the  first  evil  will  correct  the  second.  The  Congress  should 
be  strictly  a  delegated  body.  The  appointment  or  selection  of 
delegates  should  be  restricted  so  that  at  no  time  the  attendance 
would  exceed  2,000.  The  selection  of  the  delegates  should  be 
made  by  a  committee  of  the  National  Medical  Association  of 
the  countries  seeking  for  representation,  or  in  the  absence  of 
such  by  the  governments.  The  doors  of  the  Congress  should  be 
closed  to  laymen  so  far  as  membership  is  concerned.  So  far 
each  Congress  has  had  its  full  share  of  camp  followers,  who 
take  advantage  of  reduced  transportation  rates,  crowd  the 
hotels,  and  never  fail  in  taking  in  all  the  entertainments  which 
are  always  given  as  a  compliment  to  the  doctors  in  attendance ; 
as  the  present  requirements  for  membership  in  the  Congress 
are  such  that  any  one,  professional  and  layman,  who  pays  the 
stated  subscription  fee  is  admitted  and  is  entitled  to  all  the 
privileges  accorded  the  delegates.  There  are  few  cities  large 
enough  to  secure  desirable  accommodations  for  more  than  2,000 
to  3,000,  hence  the  desirability  of  restricting  the  attendance.  A 
change  in  this  direction  cannot  be  made  too  soon,  and  it  is 
hoped  that  the  authorities  of  the  next  Congress  will  consider 
this  matter  and  formulate  the  regulations  accordingly,  inas- 


13 


much  as  the  hotel  accommodations  of  Lisbon  are  greatly  inferior 
to  those  of  Madrid  and  the  other  cities  in  which  the  Cougress 
has  met  in  the  past. 

The  delegates  returning  from  Madrid  have  much  to  be 
grateful  for.  We  have  seen  Spain,  her  antiquities  and  works  of 
art.  We  have  seen  her  rugged  mountains  and  fertile  plains. 
We  have  seen  the  royal  family,  and  have  come  in  touch  with 
her  chivalrous,  hospitable  people.  We  have  become  familiar 
with  her  excellent  charitable  institutions,  her  schools  and  uni- 
versities, and  more  than  all  this,  we  have  established,  I  trust,  a 
bond  of  permanent  friendship  between  the  Spanish  and  Ameri- 
can medical  profession. 

In  conclusion,  I  desire  to  extend  my  sincere  thanks  to  Cap- 
tain Juan  Redondo,  of  the  Spanish  Navy,  who  was  my  constant 
companion  from  the  time  I  arrived  at  Madrid  until  my  depart- 
ure, and  through  whose  influence  I  received  many  courtesies 
and  much  valuable  information,  which,  without  his  friendly 
intervention,  would  not  have  been  obtainable. 

Madrid,  April  30, 1903. 


[Reprinted  from  American  Medicirie,  Vol.  VI,  No.  1,  pages  30-33, 
July  4,  1903.] 


THE  MEDICAL  INSTITUTIONS  OF  MADRID. 

BY 

NICHOLAS  SENN,  M.D., 
of  Chicago. 

The  American  physician  in  search  of  rest  or  knowledge; 
beyond  the  Atlantic  Ocean  usually  pursues  the  well-trodden 
paths  through  Germany,  France,  and  England.  The  peninsula 
of  Spain  is  not  often  frequented  by  medical  tourists.  Modern 
Spanish  medical  literature  is  not  abundant,  and  does  not  tiud 
its  way  into  the  current  of  the  world's  medical  literature 
to  the  extent  it  should.  The  medical  institutions  of  Spain 
are  not  sufficiently  known  to  the  outside  world  to  be 
estimated  correctly  in  the  scale  of  modern  advanced 
requirements.  The  fourteenth  International  Medical  Con- 
gress recently  held  in  Madrid  will  do  much  to  bring  the 
scientific  work  of  the  Spanish  practitioners  and  investi- 
gators to  the  notice  of  their  colleagues  in  the  remaining 
countries  in  Europe  aud  far  beyond  the  seas.  A  wrong  impres- 
sion prevails  not  only  in  our  country,  but  elsewhere,  to  the  effect 
that  Spanish  medicine  is  at  a  standstill.  The  forthcoming 
volumes  of  the  Transactions  of  the  Madrid  International  Medi- 
cal Congress  will  prove  the  contrary.  The  spirit  of  the  present 
age  has  animated  the  Spanish  profession  and  makes  itself  evi- 
dent in  all  of  its  medical  institutions  and  medical  literature. 
Progress  and  investigations  are  rife  everywhere,  and  have 
wrought  results  well  calculated  to  astonish  visitors.  1  am  con- 
fident every  one  who  attended  the  Congress  at  Madrid  will 
return  with  a  more  favorable  opinion  of  the  part  Spain  is  taking 
in  the  advancement  of  the  science  and  art  of  medicine  if  he 
utilized  his  time  to  advantage  in  visiting  and  studying  its  medi- 
cal institutions.  The  present  Spanish  medical  literature  is  not 
extensive,  but  highly  creditable.  I  will  cite  only  two  instances 
showing  its  character.  The  best  current  medical  publication  is 
undoubtedly  the  Revista  Ibero-Americayia  de  Ciencias  Medicas, 
a  quarterly  journal  founded  by  the  late  Professor  Federico 
Rubio  y  Gali.  It  is  a  credit  to  medical  journalism,  the  300 
pages  of  each  issue  being  the  newest  and  the  best  in  the  field  of 
recent  medical  progress.  The  illustrations,  colored  and  half- 
tone, are  numerous  and  artistic.  Under  the  first  heading  it 
brings  valuable  clinical  contributions;  then  follow  original  sci- 
entific articles,  aud  finally  review  of  reviews,   bibliography, 


and  varieties.  Another  among  the  many  recent  publications  is 
the  "  El  Laboratorio  Central  de  Sanidad  Militar."  This  book 
of  322  pages,  profusely  illustrated  with  excellent  photographic 
reproductions,  gives  the  history  and  minute  description  of  the 
laboratory  of  the  medical  departments  of  the  army  and  navy. 
I  have  alluded  to  these  publications  only  to  indicate  the  type 
and  character  of  the  Spanish  medical  literature  of  the  present 
day  in  order  to  show  that  the  profession  is  wide  awake,  and  con- 
tributes its  full  share  to  the  scientitic  work  of  the  age  we  live  in. 
Central  University. —Spa,in  has  probably  more  universities 
to  the  number  of  its  inhabitants  than  any  other  country.  The 
one  in  Madrid  is  called  the  Central  University  to  distinguish  it 
from  the  rival  institutions  inanumber  of  the  smaller  provincial 
cities.  The  ancient  Universite  d'  Alcala  de  Henares  was  abol- 
ished in  1836,  and  in  its  place  the  University  of  Madrid  was 
created,  with  the  faculties  of  law  and  canon  law.    The  present 


^^ 

-* 

InMM 

mi 

«w»«w-^H 

Perspective  of  a  street. 


name  of  the  University  was  adopted  in  1850,  and  at  that  time 
the  faculties  of  law,  philosophy  and  letters,  sciences,  medicine, 
and  pharmacy  were  installed.  Later  the  medical  and  pharma- 
ceutical departments  were  assigned  new  quarters.  The  corps  of 
professors  and  instructors  is  a  very  large  one,  and  the  different 
courses  long  and  thorough.  The  library  is  large  and  contains 
some  very  rare  books,  among  them  a  copy  of  the  "  Bible  Com- 
pluteuse,"  the  only  one  in  Spain,  and  many  remarkable  manu- 
scripts. Among  these  should  be  mentioned  the  Testament  and 
Codicil  of  Cardinal  de  Villanueva  and  a  Hebrew  Bible. 

San  Carlos  College  of  Medicine.— This  is  the  medical  depart- 
ment of  the  Central  University.  The  school  was  founded  in 
1780  by  Charles  III,  and  occupies  at  present  an  ancient  building 
in  Atocha  street,  104-106.  Professor  Julian  Calleja  y  Sanchez  is 
dean.  The  professors,  assistant  professors,  and  instructors 
number  61.  The  course  of  study  extends  over  seven  years. 
The  anatomic  museum  contains  a  very  extensive  collection  of 


8 

models,  skeletons,  bones,  and  dried  specimens  from  the  dissect- 
ing-room, splendid  object  lessons  for  the  students  of  anatomy. 
The  dissecting-room  is  large,  well  lighted,  clean,  and  amply 
supplied  with  material  on  marble  slabs  of  the  most  practical 
design.  The  pathologic  museum  has  a  rich  collection  of  speci- 
mens illustrating  all  phases  of  disease,  and  so  arranged  that 
they  can  be  studied  to  advantage  with  the  least  possible  amount 
of  handling.  In  the  obstetric  department  I  took  particular 
notice  of  a  series  of  models  in  plaster  descriptive  of  the  differ- 
ent stages  of  labor,  a  material  which  must  be  a  great  aid  in 
teaching  this  part  of  the  healing  art.  The  physiologic  depart- 
ment is  well  supplied  with  animals  for  experimental  purposes, 
and  a  splendid  assortment  of  the  most  modern  instruments  for 
teaching  and  scientific  research.  The  wooden  benches  in  the 
lecture-room  would  be  objected  to  by  our  more  fastidious  stu- 
dents, but  they  have  done  service  here  for  a  long  time,  and  so 
far  they  have  not  been  made  the  cause  at  any  time  of  any  of  the 
student  demonstrations  so  common  here.  I  visited  the  college 
on  a  Sunday  forenoon,  and  found  the  assistant  professor  of  his- 
tology hard  at  work  in  his  laboratory.  Valuable  original 
research  is  in  progress  here,  and  the  work  is  carried  on  with 
much  enthusiasm  by  teachers  and  students.  The  bacteriologic 
laboratory  is  up  to  date,  and  this  part  of  the  curriculum  is  in 
high  favor  with  the  students.  The  number  of  students  who  are 
in  attendance  now  does  not  exceed  400.  The  library  contains 
50,000  volumes,  among  them  many  rare  parchments  and  manu- 
scripts. Beside  this  one  there  are  seven  other  medical  colleges 
in  Spain,  but  the  power  to  grant  diplomas  is  limited  to  the  San 
Carlos.  If  a  licentiate  of  any  other  college  is  desirous  to  acquire 
the  title  M.D.,  he  must  attend  another  year  the  instructions  at 
the  San  Carlos  before  he  can  come  up  for  the  final  examination 
for  the  degree.  Licentiates  of  any  of  the  schools  are  privileged 
to  practise,  but  are  not  permitted  to  make  use  of  the  title  M.I). 
It  is  estimated  that  the  present  number  of  medical  students  in 
the  different  colleges  is  somewhere  in  the  neighborhood  of 
2,000. 

Practice  of  Medicine  in  Spain. — Like  most  of  the  civilized 
countries  Spain  is  well  supplied  with  doctors.  The  pay  received 
by  medical  officers  of  the  army  and  navy  is  a  fair  indication  of 
the  average  income  of  the  general  practitioner.  This  basis  is 
very  low  in  Spain.  One  of  my  friends  in  the  navy  has  served 
his  country  for  23  years,  has  reached  the  rank  of  captain  and  is 
paid  only  ^60  a  mouth.  His  duties  are  so  exacting  that  he  has 
little  opportunity  to  increase  his  income  by  private  practice,  so 
he  has  to  figure  on  his  salary  to  support  himself  and  his  family, 
consisting  of  wife  and  four  children.  From  one  to  two  dollars 
is  the  average  charge  for  a  professional  visit  in  Madrid,  and  the 


fees  for  obstetric  service  and  surgical  ojDerations  are  correspond- 
ingly small.  Twenty  thousand  dollars  a  year  is  considered  a 
princely  income  enjoyed  only  by  one  or  two  practitioners  of 
great  repute  in  Madrid,  and  from  §1,000  to  .$5,000  a  year  is 
the  limit  of  a  busy  practitioner.  The  social  standing  of  the 
Spanish  physicians  is  not  so  high  as  in  Germany  and  England, 
but  compares  favorably  with  that  of  the  American  doctor. 

Charitable  Institutions.— H ihe  civilization  of  a  nation  is  to 
be  measured  by  the  number  of  charitable  institutions  then 
Spain  heads  the  list.  The  Spaniard  has  often  been  represented 
as  being  fierce  and  cruel.  From  what  I  have  seen  I  am  satisfied 
there  is  more  cruelty  practised  in  Chicago  on  man  and  beast  in 
one  day  than  in  Madrid  in  a  month.  The  family  ties  in  Spain 
are  more  tender  than  with  us.  Unprovoked  violence  and 
cruelty  are  rare.  The  sense  of  humanity  is  keen  and  active. 
The  nobility  of  the  character  of  the  Spanish  people  is  best 
shown  by  the  many  charitable  institutions  for  the  poor,  the  sick, 
the  orphans,  the  homeless,  and  the  aged.  The  street  beggar  in 
this  city  has  no  excuse  for  practising  his  nefarious  trade.  If  he 
is  deserving  of  charity  he  will  find  it  in  one  of  the  many  institu- 
tions established  and  maintained  for  this  purpose.  Our  well 
meaning  charitably  disposed  people  can  learn  many  a  practical 
lesson  by  looking  into  the  manner  in  which  the  government 
and  the  people  of  Spain  take  care  of  their  deserving  poor.  The 
Sisters  of  Charity,  St.  Vincent  de  Paul,  the  oldest  and  best  order 
of  the  Catholic  Church,  are  present  everywhere  in  Spain  and  in 
large  numbers.  They  are  in  charge  of  nearly  all  of  the  hospitals, 
take  care  of  the  orphans  and  aged,  and  educate  the  children. 
The  influence  of  this  order  is  in  evidence  in  nearly  all  of  the 
charitable  institutions.  The  cornet,  the  headdress  of  the 
Sisters  of  Charity,  is  an  emblem  of  charity  of  the  noblest 
kind,  honored  and  respected  by  all  nations.  In  Madrid 
alone  there  are  11  asylums,  2  hospices,  2  institutes,  and 
5  houses  of  refuge  for  the  benefit  of  orphans,  the  aged,  widows, 
the  crippled,  and  helpless.  Many  of  these  noble  institutions 
have  been  founded  and  are  maintained  by  Avealthy  citizens  and 
aid-societies.  The  Institute  for  Epileptics  is  a  good  indication  of 
the  concern  of  the  government  for  its  unfortunates.  Where  is 
the  city  that  can  make  the  same  showing  of  the  wise  distribu- 
tion of  needed  charity  ?  What  has  Chicago  done  for  its  imbeciles 
and  epileptics?  Let  those  who  charge  the  Spaniards  with 
cruelty  come  here  and  see,  and  if  they  can  leave  prejudice  at 
home  they  will  comprehend  what  true  charity  means. 

JTospiYa/.s.— Madrid  may  well  pride  itself  on  its  hospital 
facilities  for  the  army  and  the  sick  poor.  The  well-to-do 
families  are  opposed  to  hospital  treatment ;  the  consequence  is 
that  there  are  no  elegant  private  hospitals  such  as  we  find  in 


our  country  in  nearly  every  city  of  sufficient  size  to  support 
such  an  enterprise.  It  is  not  long  since  the  same  prejudice 
against  hospitals  existed  in  our  country.  The  objections  have 
been  overcome  by  the  establishment  of  home-like  private  hos- 
pitals and  by  the  trained  female  nurse.  The  trained  female 
nurse  must  be  created  first  and  then  private  hospitals  will  fol- 
low as  a  necessary  sequence.  The  greatest  fault  of  the  Spanish 
hospitals  is  not  to  be  found  in  the  buildings  but  in  the  absence 
of  the  trained  female  nurse.  Nearly  all  of  the  nursing  in  the 
hospitals  is  done  by  the  Sisters  of  Charity.  They  are  a  noble 
band  of  intelligent,  willing,  self-sacrificing  women,  but  lack  the 
necessary  training  in  the  care  of  the  sick  and  as  helpmates  in 
the  operating-room.  In  our  country  the  Sisters  have  recog- 
nized the  necessity  of  such  training,  have  received  the  requisite 
instruction,  and  are  now  managing  the  best  training  schools 
for  lay  nurses.  Let  the  Sisters  in  Spain  follow  their  example 
and  better  nursing  and  private  hospitals  for  the  wealthy  will 
follow  in  rapid  succession. 

Military  ffospiYa^.— The  Military  Hospital  (Hospital  Mili- 
tar  de  Madrid  en  Carabanchel  Bajo)  was  built  eight  years  ago 


General  view  of  Military  Hospital. 

near  the  city  limits.  A  narrow  railway  and  electric  tramway 
furnish  ready  transportation  to  and  from  the  city.  The  build- 
ings or  pavilions,  24  in  number,  are  solid  brick  structures  of 
one  and  two  stories,  communicating  with  each  other  by  glass 
walled  galleries.  The  general  in  command  and  medical 
officers  occupy  the  two  elegantly  furnished  pavilions  near  the 
entrance  to  the  grounds.  The  two  surgical  pavilions  communi- 
cate with  the  operating-room.  The  preparation,  anesthesia, 
instrument  and  operating-rooms  are  in  a  separate  pavilion  of 
modern  design.    All  of  the  buildings  are  lighted  by  electricity, 


the  sewerage  is  perfect,  and  ample  provisions  have  been  made  for 
bathing.  All  the  buildings  are  heated  by  hot  air.  The  wards 
are  well  lighted  and  ventilated  and  kept  scrupulously  clean. 
The  institution  has  a  well-equipped  bacteriologic  laboratory 
and  a  museum  rich  in  pathologic  specimens  and  a  large  collec- 
tion of  plaster  models  illustrating  many  pathologic  conditions, 
more  particularly  diseases  of  the  skin  and  syphilitic  lesions 
in  all  stages  of  the  disease.  The  food  is  plain  but  nourishing 
and  healthful.  The  waterworks  supply  the  institution  with 
345  cubic  meters  of  pure  water  every  day,  being  690  liters  for 
each  patient.  Isolation  pavilions  make  adequate  provision  for 
infectious  and  mental  diseases.    The  hospital  is  intended  to 


Operating  paviliou. 

furnish  room  for  400  patients,  but  in  case  of  need  can  accommo- 
date twice  that  number.  The  storeroom  for  medical  supplies, 
the  depot  for  amljulances,  the  stables  for  the  horses,  the  disin- 
fection-room, aud  the  steam  laundry  are  all  constructed  upon 
plans  calculated  to  yield  the  best  results  upon  an  economic 
basis.  From  10  to  12  surgeons  are  daily  in  attendance.  Only 
the  surgeon-in-chief  resides  in  the  hospital.  The  sick  are  cared 
for  by  20  Sisters  of  Charity  and  a  sufficient  number  of  men  from 
the  sanitary  corps.  The  interior  of  the  operating-room,  the 
make-up  of  the  instrumentarium,  the  dressing  material,  and  all 
the  facilities  for  asepsis  are  sufficient  guarantee  that  modern 
surgery  has  found  its  way  into  this  hospital.  The  institution 
is  one  of  which  the  military  surgeons  of  Spain  may  well  feel 


proud.  The  surgeons  on  duty  can  spend  their  leisure  time  in  a 
large,  elegantly  furnished  room  in  which  the  members  of  the 
Military  Section  at  the  close  of  their  visit  to  the  hospital  were 
served  a  most  enjoyable  lunch. 

Clinical  Hospital.— The  Clinical  Hospital  (Hopital  Clinique 
de  la  Faculte  de  Medecine)  is  an  old  somewhat  dingy  building 
adjacent  to  the  San  Carlos  College.  It  has  a  capacity  of  240  beds. 
The  faculty  of  the  college  has  exclusive  control  of  the  manage- 
ment of  the  hospital  and  all  of  the  clinical  instruction  is  con- 
ducted here.  The  wards  have  from  10  to  24  beds.  Professor 
San  Martin  is  the  chief  surgeon. 

The  operating-room  is  small  and  is  separated  from  the  still 
smaller  auditorium  occupied  by  the  students  by  a  glass  parti- 
tion. Professor  San  Martin  is  evidently  a  firm  believer  in 
asepsis.  On  the  day  of  my  visit  he  operated  on  a  patient  with 
inoperable  carcinoma  of  the  rectum  and  demonstrated  his  new 
operation  for  the  formation  of  an  artificial  anus. 

The  patient  was  anesthetized  by  the  introduction  of  chloro- 
form vapor  through  two  rubber  tubes  inserted  into  the  nares. 
The  abdomen  was  opened  in  the  left  iliac  region  in  the  usual 
manner.  A  transverse  incision  two  to  three  inches  in  length  was 
then  made  through  the  skin  and  fascia  lata  two  inches  below 
the  iliac  crest  and  a  little  behind  a  vertical  line  from  the  ante- 
rior superior  spine  of  the  ilium.  After  making  a  short  cross  cut 
through  the  fascia  a  tunnel  was  made  with  hemostatic  forceps 
underneath  the  sartorius  muscle  into  the  iliac  fossa  and  the 
sigmoid  flexure  was  then  drawn  into  this  submuscular  passage 
until  the  apex  of  the  loop  was  on  a  level  with  the  skin  of  the 
external  incision,  in  which  position  it  was  fixed  with  sutures 
embracing  the  mesosigmoid.  The  abdominal  incision  was 
closed  with  buried  continuous  catgut  sutures.  The  bowel  will 
be  opened  after  it  has  become  securely  adherent. 

The  operator  calls  this  operation  the  valve  method,  and 
maintains  that  the  muscles  surrounding  the  loop  of  intestine 
act  as  an  efficient  sphincter,  which  prevents  leakage  between 
the  bowel  movements.  The  clinical  material  of  this  hospital  is 
utilized  to  the  best  advantage  for  the  students.  Two  to  three 
students  are  assigned  to  each  important  case.  They  are 
required  to  write  up  a  complete  history  of  the  case,  make  a 
thorough  examination,  and  visit  the  patient  regularly.  This 
method  of  clinical  instruction  has  certainly  much  to  recom- 
mend it  to  the  attention  and  for  the  consideration  of  clinical 
teachers.  It  would,  however,  be  difficult  if  not  impossible  to 
secure  such  liberties  with  patients  in  any  part  of  our  country. 

Provincial  Hospital —This,  hospital  (Hopital  Provincial) 
is  more  than  200  years  old.  It  was  founded  in  1587  by  Philip  II, 
under  the  name  of  La  Encarnacion  y  San  Roque.  It  is  an 
immense  square  building  with  a  central  court.  The  windows 
are  small,  the  solid    stone  walls  six   or  more  feet  in  thick- 


8 


ness,  features  -which  impart  to  the  building  a  fortress-like 
appearance.  The  wide  corridors  all  around  the  open  court  are 
protected  against  cold,  wind  and  rain  by  a  siding  of  window- 
glass.  The  court  has  been  converted  into  a  beautiful  flower 
garden.  The  wards  are  large,  with  high  ceilings,  and  all  the 
floors  are  made  of  tiling.  The  furnishings  of  the  wards,  includ- 
ing the  beds,  are  plain,  but  comfortable.  Sixty  Sisters  of 
Charity  take  care  of  the  patients — never  less  than  1,000.  The 
professors  of  San  Carlos  College  give  their  gratuitous  services 
to  this  institution,  but  so  far  have  not  been  permitted  to  give 
clinical  instruction.  A  movement  is  now  on  foot  to  secure  this 
privilege,  and  it  is  hoped  that  the  request  will  be  granted. 
The  clinical  material  here  is  simply  immense,  and  its  utiliza- 
tion for  clinical  teaching  would  be  a  great  acquisition  to  the 
teaching  facilities  of  the  college  and  would  open  up  a  rich  mine 
for  scientific  clinical  work.  The  hospital  has  two  operating- 
rooms  :  the  new  one  in  a  separate  pavilion  meets  all  the  require- 
ments for  modern  aseptic  surgery.  Sunday  is  the  visiting  day. 
I  happened  to  visit  the  hospital  on  that  day  and  found  wards, 
halls  and  corridors  crowded  with  relatives  and  friends  of  the 
patients.  Loud  talking,  laughing  and  smoking  gave  the  hos- 
pital the  appearance  of  a  public  market,  rather  than  a  place  for 
the  injured  and  sick.  Corpses  were  being  carried  out,  new 
patients  were  brought  in,  all  of  which  made  a  scene  that  could 
not  be  reproduced  in  any  of  our  hospitals.  The  Provincial  Hos- 
pital is  for  the  sick  poor  of  Madrid  what  the  Bellevueis  for  Xew 
York,  the  Charity  Hospital  for  New  Orleans,  and  Cook  County 
Hospital  for  Chicago.  The  expenses  of  the  hospital  are  paid 
out  of  the  public  funds  of  the  Province,  as  no  provision  what- 
ever is  made  for  pay  patients. 

Princess  Hospital.— The  Princess  Hospital  (Hospital  de  la 
Princesa)  is  another  great  public  charity  in  the  very  heart  of 
the  city.  It  was  founded  in  1852  by  Queen  Isabella  II  in  com- 
memoration of  the  birth  of  the  Princess  of  Asturia.  The  three- 
story  brick  pavilions  with  inside  glass-protected  corridors  face 
a  capacious  open  court  beautified  by  subtropical  trees  and 
shrubs,  flower  beds,  fountains  and  winding  paths.  It  can 
accommodate  225  patients.  The  only  requirements  for  admis- 
sion are  poverty  and  illness.  The  wainscoting  of  the  rooms 
and  halls,  as  well  as  the  floors,  are  in  glazed  tiling.  The  oper- 
ating-room is  small  but  well  adapted  for  aseptic  work.  The 
care  of  the  sick  is  in  charge  of  30  Sisters  of  Charity.  I  found 
here  a  number  of  trained  orderlies,  who  assist  in  the  nursing 
and  in  the  operating-room  and  apply  many  of  the  dressings. 
These  men  receive  their  training  in  the  San  Carlos  College, 
where  they  attend  lectures  and  receive  practical  instruction  for 
two  years.    At  the  end  of  that  time  and  after  having  passed  a 


satisfactory  examination  they  receive  a  certificate  which  entitles 
them  to  serve  as  assistants  to  physicians.  The  training  and 
scope  of  work  corresponds  with  those  of  the  barber  surgeons  of 
Russia  and  other  European  countries.    One  of  these  orderlies 


Princess  Hospital. 

is  the  anesthetizer  of  the  hospital.  The  anesthetic  in  general 
use  in  Spain  is  chloroform.  The  instruments  and  dressing 
materials  are  kept  in  a  separate  room  near  the  operating-room. 
Suture  and  ligature  material  is  purchased  already  prepared  and 


Court  of  Princess  Hospital. 

is  kept  ready  for  use  in  hermetically  sealed  glass  bottles.  The 
attending  staff  is  composed  of  seven  physicians  and  surgeons 
who  receive  their  appointment  by  concour.  They  are  assisted 
by  26  agreges  and  85  assistant  physicians.    Drs.  Cospedal  and 


10 

Ustaris  are  the  principal  operating  surgeons.  In  this  as  well  as 
in  most  of  the  hospitals  in  Spain  there  are  no  permanent 
internes.  The  young  doctors  who  serve  in  place  of  our  internes 
are  appointed  by  competitive  examination  and  hold  their 
positions  until  they  are  advanced  and  become  members  of  the 
stati'.  This  hospital  has  three  such  internes,  who  serve  alter- 
nately for  24  hours.  They  are  the  only  members  of  the  medical 
corps  who  receive  a  small  salary.  Two  days  out  of  three  they 
attend  to  their  private  practice.  Three  priests  serve  the  spiritual 
needs  of  the  inmates  in  the  same  manner,  occupying  the  same 
room  every  third  day.  A  small  clinical  laboratory  and  a 
pathologic  museum  represent  the  scientilic  aspects  of  this  hos- 
pital. The  polyclinic  attached  to  this  hospital  is  nearing  com- 
pletion. Sixteen  physicians  are  in  attendance  at  different 
times,  all  of  whom  render  their  services  gratuitously.  In  Spain, 
like  in  our  country,  the  medical  profession  is  expected  to  give 
to  the  hospitals  their  time  and  labor  free  of  charge. 

The  arrangements  of  the  interior  of  the  new  polyclinic  are 
very  practical,  which  enables  the  attending  staff  to  dispose 
of  the  large  clientele  quickly  and  in  a  most  satisfactory 
manner.  The  specialties  that  receive  recognition  here  are  dis- 
eases of  the  urinary  organs,  nervous  system,  larynx,  eye,  ear, 
digestive  tract,  gynecology,  and  diseases  of  children.  The 
annual  expense  of  the  polyclinic  alone  amounts  to  138,320 
pesetas.    Dr.  Jose  Ustaris  is  chief  of  the  attending  staff. 

Riibio  Institute.— The  "  Institut  de  Therapeutique  Opera- 
toire"  is  universally  known  under  the  name  Rubio  Institute, 
in  memory  of  the  late  Professor  Federico  Rubio  y  Gali,  its 
founder.  It  is  the  only  hospital  in  Madrid  devoted  exclusively  to 
surgical  cases.  The  cornerstone  was  laid  by  the  Queen  Regent 
in  July,  1895,  and  its  doors  opened  to  the  sick  poor  in  need  of 
surgical  treatment  on  the  first  day  of  October,  1896.  Professor 
Rubio  was  the  most  eminent  surgeon  that  Spain  produced 
during  the  latter  part  of  the  nineteenth  century.  He  was 
highly  esteemed  not  only  by  his  colleagues  and  students,  but 
also  by  the  entire  population  of  Madrid.  He  contributed 
liberally  toward  the  building  and  support  of  the  hospital.  He 
died  at  an  advanced  age  June  28,  1902.  He  remained  at  his  post 
of  duty  until  the  day  before  his  death.  At  his  request  he  was 
buried  in  the  small  chapel  on  the  hospital  grounds,  where  a 
marble  slab  in  the  floor  in  front  of  the  altar  with  suita])le 
inscription  on  a  silver  plate  marks  the  place  where  his  remains 
are  at  rest.  The  principal  motive  that  induced  Professor  Rubio 
to  found  this  hospital  was  to  establish  a  postgraduate  school 
for  the  study  of  surgery.  The  pupils,  graduate  physicians,  on 
payment  of  250  pesetas  have  the  privilege  to  attend  operations 
and  receive  instruction  for  two  consecutive  years.    The  hos- 


u 


pital  is  situated  upon  a  high  bluff  at  the  northern  boundary  of 
the  city,  in  full  view  of  the  Ijeautifnl  Moncloa  valley,  watered 
by  the  Manzares  river.  The  grounds  are  park-like,  shaded  by 
groves  of  young  eucalyptus  trees.  The  brick  and  stucco  pavil- 
ions are  one-story  high,  and  the  two  main  wards,  with  24  beds 
each,  are  connected  with  the  operating-room  by  galleries.  The 
operating-room  leaves  nothing  to  be  desired,  and  is  supplied 
with  all  possible  facilities  for  aseptic  operations.  The  hospital 
is  lighted  by  electricity  and  heated  by  steam.  The  closets  and 
bathrooms  compare  well  with  those  of  our  best  hospitals.  Up 
to  date  30  beds  have  been  endowed  by  the  payment  of  12,700 
pesetas  for  each  by  friends  of  the  deceased  founder.  Upon  an 
oval  silver  plate  on  the  wall  above  the  bed  the  name  of  the 
donor  is  inscribed.  An  isolation  pavilion  with  six  beds  in  as 
many  rooms  is  set  aside  for  infected  cases.  Above  the  entrance 
door  and  in  the  vestibule  of  this  building  will   be  found  the 


Ruble  Institute. 


names  of  the  teachers  of  Rubio.  A  separate  two-story  building 
is  vised  as  polyclinic  for  outdoor  patients.  The  institution  is 
managed  by  a  board  of  directors,  of  which  the  Queen  is  honor- 
ary president. 

The  Rubio  Institute  is  the  best  hospital  in  Madrid,  and  the 
patients,  although  all  of  them  are  cases  of  charity,  receive  the 
same  care  and  attention  as  in  any  of  our  best  private  hospitals. 
It  is  the  only  hospital  in  the  city  that  has  a  training  school  for 
female  nurses.  Tlie  present  number  of  pupils  in  the  school  is 
12.  The  training  consists  of  lectures  given  by  the  members  of 
the  staff,  demonstrations,  and  practical  instruction.  At  the  end 
of  three  years  they  are  examined,  and  if  found  qualified,  receive 
a  certificate  which  entitles  tliem  to  follow  their  profession  out- 
side of  the  institution.  The  headdress  of  these  nurses  is  a  very 
unique  one.  It  consists  of  a  hood  rather  than  a  cap  which 
leaves  only  the  face  part  of  the  head  exposed.  The  outside  of 
this  hood  is  blue,  the  inside  lining  orange  yellow.    The  hospital 


12 


is  to  be  congratulated  upon  this  radical  change  in  the  nursing 
of  its  inmates.  It  has  become  a  pioneer  in  Spain  in  the  impor- 
tant matter  of  nursing.  The  example  it  has  established  can- 
not fail  in  inducing  other  institutions  to  do  the  same,  and  when 
I  visit  Spain  again  I  hope  to  find  that  all  of  the  Sisters  of 
Charity  serving  in  hospitals  will  have  become  trained  nurses, 
and  that  every  large  hospital  will  have  its  own  training  school 
for  lay  female  nurses.  With  the  realization  of  such  a  radical 
change  in  the  care  of  the  sick,  the  hospitals  of  Madrid  and 
throughout  Spain  Avill  come  in  line  with  those  of  any  other 
country,  old  and  new,  I  have  made  brief  allusion  only  to  a 
few  of  the  largest  hospitals  of  Madrid.  The  number  of  hospitals 
is  simply  astonishing,  considering  the  size  of  the  city — 17  in  all, 
beside  the  many  asylums,  hospices,  homes,  and  institutes. 
The  hospital  for  children  has  200  beds,  the  smaller  ones  from 
12  to  50.  The  hospital  for  the  insane  is  an  ideal  institution 
with  a  branch  at  the  seaside,  Villajoyosa,  where  the  inmates 
spend  the  summer  months.  Music,  dancing,  theaters,  are 
only  some  of  the  diversions  regularly  furnished  for  the  unfor- 
tunate patients.  Madrid  has  also,  strange  to  say,  a  homeopathic 
hospital.  The  Institute  Homeopathique  et  Hopital  de  San  .lose 
owes  its  origin  to  the  liberality  of  Marquis  de  Nunez.  The  four 
chairs  for  the  elucidation  of  the  homeopathic  doctrine  and 
practice  were  founded  by  the  Marquis,  and  since  his  death 
have  been  supported  by  the  government.  Fifteen  thousand 
patients  have  been  treated  in  this  institution  since  its  founda- 
tion in  1878.  The  French  and  Italian  residents  have  made  pro- 
vision for  their  poor  sick  countrymen  by  the  establishment 
and  maintenance  of  hospitals  of  their  own,  the  former  with  20 
beds. 

Among  the  many  societies  formed  with  the  object  of  diffus- 
ing and  popularizing  humanity  in  all  its  phases,  I  will  only 
mention  the  Red  Cross  Society  and  the  Society  for  the  Protec- 
tion of  Infants. 

The  Red  Cross  Society  of  Spain  is  well  organized  for  effective 
work  in  peace  as  well  as  in  war  when  it  is  called  upon  to  exer- 
cise its  humane  functions.  Its  loyalty  to  the  intent  and  regula- 
tions of  the  Geneva  Convention  was  amply  demonstrated  dur- 
ing the  Spanish-American  war.  Its  activity  in  relieving  suffer- 
ing and  distress  in  sudden  emergencies  at  home  is  well  known. 
Of  the  objects  of  the  "Societe  Protectrice  des  Enfants  "  the 
following  is  said  :  "  Cette  Societe  humanitaire  a  pour  objet  de 
sauvegarder  la  vie  des  enfants  par  tous  les  moyens  possibles, 
depuis  leur  naissance,  contre  tous  les  dangers  auxquels  les 
expose  leur  faibless,  de  les  proteger,  quelle  quesoit  leur  classe 
ou  conditions  contre  1'  abandon,  la  misere,  les  mauvais  traite- 
ments,  et  les  exemple  immoraux,  et  de  rendre  populaires  les 


13 

preceptes  les  plus  utiles  de  V  Hygiene  et  de  la  Morale,  eu  union 
des  preceptes  religieux."  Let  those  who  live  far  away  from 
Spain  and  who  have  heard  of  the  barbarity  of  its  people  come  to 
Madrid  and  see  its  magnificent  works  of  art,  its  splendid 
schools,  its  excellent  hospitals,  its  many  homes  and  asylums 
for  all  classes  of  unfortunates,  and  its  humane  societies.  To  all 
of  these  I  say,  reserve  your  judgment  until  you  "  come  and 
see." 

On  board  S.  S.  "  Princess  Irene."  harbor;of  New,  York,  May  14,  1903. 


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